The Patient Safety Subcommittee requested a review of the science and policy issues regarding the rapidly emerging public health epidemic of prescription opioid-related morbidity and mortality in the ...United States. Over 100,000 persons have died, directly or indirectly, from prescribed opioids in the United States since policies changed in the late 1990s. In the highest-risk group (age 35–54 years), these deaths have exceeded mortality from both firearms and motor vehicle accidents. Whereas there is evidence for significant short-term pain relief, there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction. The objectives of the article are to review the following(1) the key initiating causes of the epidemic; (2) the evidence for safety and effectiveness of opioids for chronic pain; (3) federal and state policy responses; and (4) recommendations for neurologists in practice to increase use of best practices/universal precautions most likely to improve effective and safe use of opioids and to reduce the likelihood of severe adverse and overdose events.
The Centers for Disease Control and Prevention recognizes Medicaid as a high-risk population for fatal opioid overdose. Further research is needed to identify factors that put Medicaid patients at ...increased risk.
To determine whether patterns of opioid use are associated with risk of opioid-related mortality among opioid users.
This is a retrospective cohort study.
In total, 150,821 noncancer pain patients aged 18-64 years with ≥1 opioid prescription, April 2006 to December 2010, Washington Medicaid.
Average daily dose (morphine equivalents), opioid schedule/duration of action, sedative-hypnotic use.
Compared with patients at 1-19 mg/d, risk of opioid overdose death significantly increased at 50-89 mg/d adjusted hazard ratio (aHR), 2.3; 95% confidence interval (CI), 1.4-4.1, 90-119 mg/d (aHR, 4.0; 95% CI, 2.2-7.3), 120-199 mg/d (aHR, 3.8; 95% CI, 2.1-6.9), and ≥200 mg/d (aHR, 4.9; 95% CI, 2.9-8.1). Patients using long-acting plus short-acting Schedule II opioids had 4.7 times the risk of opioid overdose death than non-Schedule II opioids alone (aHR, 4.7; 95% CI, 3.3-6.9). Sedative-hypnotic use compared with nonuse was associated with 6.4 times the risk of opioid overdose death (aHR, 6.4; 95% CI, 5.0-8.4). Risk was particularly high for opioids combined with benzodiazepines and skeletal muscle relaxants (aHR, 12.6; 95% CI, 8.9-17.9). Even at opioid doses 1-19 mg/d, patients using sedative-hypnotics concurrently had 5.6 times the risk than patients without sedative-hypnotics (aHR, 5.6; 95% CI, 1.6-19.3).
Our findings support Federal guideline-recommended dosing thresholds in opioid prescribing. Concurrent sedative-hypnotic use even at low opioid doses poses substantially greater risk of opioid overdose.
BACKGROUND:Long-term work disability is known to have an adverse effect on the nation’s labor force participation rate. To reduce long-term work disability, the Washington State Department of Labor ...and Industries established a quality improvement initiative that created 2 pilot Centers of Occupational Health and Education (COHE).
OBJECTIVES:To document the level of work disability in a sample of injured workers with musculoskeletal injuries and to examine (8-y) work disability outcomes associated with the COHE health care model.
RESEARCH DESIGN:Prospective nonrandomized intervention study with nonequivalent comparison group using difference-in-difference regression models.
SUBJECTS:Intervention group represents 18,790 workers with musculoskeletal injuries treated by COHE providers. Comparison group represents 20,992 workers with similar injuries treated within the COHE catchment area by non-COHE providers.
MEASURES:Long-term disability outcomes include(1) on disability 5 years after injury; (2) received a state pension for total permanent disability; (3) received total disability income support through the Social Security Disability Insurance program; or (4) a combined measure including any one of the 3 prior measures.
RESULTS:COHE patients had a 30% reduction in the risk of experiencing long-term work disability (odds ratio=0.70, P=0.02). The disability rate (disability days per 1000 persons) over the 8-year follow-up for the intervention and comparison groups, respectively, was 49,476 disability days and 75,832 disability days.
CONCLUSIONS:Preventing long-term work disability is possible by reorganizing the delivery of occupational health care to support effective secondary prevention in the first 3 months following injury. Such interventions may have promising beneficial effects on reversing the nation’s progressively worsening labor force participation rate.
By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In ...2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used.
Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.
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