Annals of Internal Medicine

Editorial

Chronic Noncancer Pain Management and Opioid Overdose: Time to Change Prescribing Practices
t this writing, opioids are the most commonly prescribed class of medication in the United States (1). Prescription of some opioids, such as methadone, has increased more than 800% in the past 10 years (2). This increase in opioid prescribing has caused an increase in overdoses and deaths. Opioid overdose is among the most common causes of death nationwide (3). The increase in deaths due to prescription opioids is a major public health priority and not just a concern for individual physicians and their patients. It is easy to blame the growing epidemic of opioid overdose and death on manipulative patients who misrepresent pain symptoms to obtain drugs to abuse or sell. A recent report (4) on overdose deaths in West Virginia found that 51% occurred in persons who had never actually been prescribed an opioid (that is, prescription diversion) and that another 20% occurred in persons who had received prescriptions from 5 or more physicians (that is, doctor shopping). In an accompanying editorial (5), we acknowledged the role of the patient in adverse events from opioids but also suggested opportunities for physicians to stem the rise in prescription opioid deaths. In this issue, Dunn and colleagues (6) identify a potential role for physicians in reducing prescription opioid overdose and death. The authors examined stably insured patients with a range of noncancer pain diagnoses in the Group Health Cooperative network in Washington. Doctor shopping with multiple opioid prescriptions was probably minimal in this setting, which had a systemwide electronic health record. Patients most likely to seek drugs from multiple physicians probably left the system, as did one third of the study sample during the 4-year follow-up. Yet, even in this closed system, the rates of documented serious overdose incidents and deaths were substantial (117 and 17 per 100 000 person-years, respectively). True rates were probably even higher because of inevitable gaps in the reporting of these events. A disturbing observation from Dunn and colleagues study was that many overdose incidents might have been averted by changes in prescriber practices. First, the raw data (unadjusted) revealed more overdoses in patients who were diagnosed with depression or substance abuse or who were concurrently prescribed sedative-hypnotics (for example, benzodiazepines). It is unknown whether these patients were rst treated, as they should have been, with alternative nonopioid pharmacologic and nonpharmacologic approaches (for example, physical therapy) to manage chronic pain. Regardless, depression, substance use, and benzodiazepine use are all well-known risks for adverse events from opioids (7); therefore, these persons
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require substantial education and close oversight if opioids are prescribed. The authors did not evaluate other risk factors for opioid misuse, including history of illicit drug use (because it is infrequently entered as a diagnosis). When alcohol use is recorded, it is located in the social history, where it rarely affects prescribing (8). Substance abuse screening and brief intervention protocols have been shown to reduce substance userelated problems (9) but have not been widely incorporated into physician practice (10). Physicians may fear nding an addiction, which many are unprepared to treat (11). But brief screening discussions about substance usenot just addictionare needed to reduce opioid overdose as well as other drugalcohol or drug drug interactions. A unique contribution of this study is the examination of the relationship between overdose events and the timing and morphine-equivalent dose of the prescribed drug. As expected, the authors found that risk for an adverse event was greatest shortly after the initial opioid prescription or after a rell. These data reinforce the importance of closely monitoring patients who are prescribed opioids. The authors also report a doseresponse relationship between higher morphine-equivalent doses and risk for opioidrelated overdose. Although the highest dose of opioids (100-mg morphine equivalents) was received during only 2% of the follow-up, the associated annual overdose rate was very high during that period: 1791 per 100 000 person-years. Low doses rarely resulted in adverse events. Prescribing opioids at high doses is both dangerous and questionable for indications other than methadone treatment of opioid dependence. Opioid therapy can be monitored by making an opioid agreement with the patient when therapy is initiated. The agreement is updated whenever therapy is modied. Typically, these agreements not only set out the responsibilities of both patient and provider when these drugs are used but also make clear the potential dangers of using these drugs other than as prescribed. Dunn and colleagues ndings reinforce the importance of goal-directed opioid therapy, in which continued or increased doses of opioid therapy should be contingent on clear improvements in function and quality of life (for example, resuming more normal activities) (7). Long-term opioid therapy carries too many risks to justify use without improvements in health status. Of note, the patients in Dunn and colleagues study received prescriptions primarily for short-acting opioids, namely hydrocodone and oxycodone. Although not specied, these drugs were probably in formulations with acet19 January 2010 Annals of Internal Medicine Volume 152 Number 2 123

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Editorial

Opioid Prescribing Practices

aminophen. Not only are short-acting opioids associated with greater risk for tolerance and dependence (12), a recent panel of the U.S. Food and Drug Administration (13) recommended that these combination drugs be removed because of acetaminophen-related hepatotoxicity. Acetaminophen poisoning was not examined in this study but represents yet another risk that patients and physicians should seek to reduce. Finally, Dunn and colleagues ndings strengthen the argument for an easy-to-use, real-time, prescription-drug monitoring program in which physicians can track all opioid prescriptions for a patient. Two promising systems, one designed by the Department of Health and Human Services and one by the Department of Justice, are in testing now. However, neither is fully satisfactory. To be successful, the program needs to be readily accessible for all health care clinical information systems, including pharmacies. The White House Ofce of National Drug Control Policy and other federal agencies are actively collaborating on development of this key resource to help physicians reduce patient abuse of prescriptions (for example, doctor shopping) and adverse drug interactions. It is easy to suggest time-consuming, unreimbursed approaches to improve the safety of opioid prescribing without specifying how they can be incorporated into already overburdened clinical settings. Frankly, we do not know how to increase clinical diligence without additional work, time, or money, although technology can facilitate some of these suggested practice changes. The threat to patient safety is too great to allow current pain management and opioid-prescribing practices to remain as they are. Dunn and colleagues data show the need to assess the risk for opioid misuse, provide close oversight, dose judiciously, and continually reevaluate the benet of these potentially risky drugs. Smarter, more responsible practices are the only hope to avoid tragic, avoidable deaths.
A. Thomas McLellan, PhD White House Ofce of National Drug Control Policy Washington, DC 20503 Barbara J. Turner, MSEd, MD Executive Deputy Editor

Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConictOfInterestForms.do?msNum M09-2667. Corresponding Author: A. Thomas McLellan, PhD, White House Of-

ce of National Drug Control Policy, 750 17th Street Northwest, Washington, DC 20503; e-mail, [email protected]. Ann Intern Med. 2010;152:123-124.

References
1. Kuehn BM. Opioid prescriptions soar: increase in legitimate use as well as abuse. JAMA. 2007;297:249-51. [PMID: 17227967] 2. U.S. Department of Justice Drug Enforcement Administration. ARCOS: Automation of Reports and Consolidated Orders System. Accessed at www .deadiversion.usdoj.gov/arcos/index.html on 7 December 2009. 3. Centers for Disease Control and Prevention (CDC). Unintentional poisoning deathsUnited States, 1999-2004. MMWR Morb Mortal Wkly Rep. 2007; 56:93-6. [PMID: 17287712] 4. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300:2613-20. [PMID: 19066381] 5. McLellan AT, Turner B. Prescription opioids, overdose deaths, and physician responsibility [Editorial]. JAMA. 2008;300:2672-3. [PMID: 19066389] 6. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose. A cohort study. Ann Intern Med. 2010;152:85-92. 7. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-12. [PMID: 15773874] 8. Turner BJ, McLellan AT. Methodological challenges and limitations of research on alcohol consumption and effect on common clinical conditions: evidence from six systematic reviews. J Gen Intern Med. 2009;24:1156-60. [PMID: 19672662] 9. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:280-95. [PMID: 18929451] 10. Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend. 2006;81: 103-7. [PMID: 16023304] 11. Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med. 2001;76:410-8. [PMID: 11346513] 12. Zacny J, Bigelow G, Compton P, Foley K, Iguchi M, Sannerud C. College on Problems of Drug Dependence task force on prescription opioid non-medical use and abuse: position statement. Drug Alcohol Depend. 2003;69:215-32. [PMID: 12633908] 13. Kuehn BM. FDA focuses on drugs and liver damage: labeling and other changes for acetaminophen. JAMA. 2009;302:369-71. [PMID: 19622807]

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Annals of Internal Medicine

tional Drug Control Policy, 750 17th Street Northwest, Washington, DC 20503. Dr. Turner: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

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19 January 2010 Annals of Internal Medicine Volume 152 Number 2 W-31

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