A Flood of Opioids, a Rising Tide of Deaths

Georgetown University School of Medicine, Washington, DC, USA.
New England Journal of Medicine (Impact Factor: 54.42). 11/2010; 363(21):1981-5. DOI: 10.1056/NEJMp1011512
Source: PubMed

ABSTRACT Faced with an epidemic of drug abuse and overdose deaths, the FDA has proposed a Risk Evaluation and Mitigation Strategy for prescription opioid pain relievers, involving improved education for physicians and patients about risks associated with long-acting opioids.

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    • "Although the prevalence of long-term opioid use has increased since the 1990s [20] [21] [22], opioids used as monotherapy may not be the optimal choice for many patients with acute pain due to opioids' abuse potential, associated adverse effects, and inadequate efficacy compared with other therapies for certain conditions. Contemporaneous increases in abuse, abuse-related morbidity and mortality [23] [24], and illegal diversion may lead emergency care providers to be reluctant to prescribe opioids [25]. Such opiophobia could result in inadequate analgesia if patients with inadequately managed pain are mistaken for those seeking to abuse opioids due to physician bias or patient presentation with behaviors interpreted as drug-seeking [26,27]. "
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    ABSTRACT: Abstract Undertreatment of pain (oligoanalgesia) in the emergency department is common, and it negatively impacts patient care. Both failure of appropriate pain assessment and the potential for unsafe analgesic use contribute to the problem. As a result, achieving satisfactory analgesia while minimizing side effects remains particularly challenging for emergency physicians, both in the emergency department and after a patient is discharged. Improvements in rapid pain assessment and in evaluation of noncommunicative populations may result in a better estimation of which patients require analgesia and how much pain is present. New formulations of available treatments, such as rapidly absorbed, topical, or intranasal nonsteroidal anti-inflammatory drug formulations or intranasal opioids, may provide effective analgesia with an improved risk-benefit profile. Other pharmacological therapies have been shown to be effective for certain pain modalities, such as the use of antidepressants for musculoskeletal pain, γ-aminobutyric acid agonists for neuropathic and postsurgical pain, antipsychotics for headache, and topical capsaicin for neuropathic pain. Nonpharmacological methods of pain control include the use of electrical stimulation, relaxation therapies, psychosocial/manipulative therapies, and acupuncture. Tailoring of available treatment options to specific pain modalities, as well as improvements in pain assessment, treatment options, and formulations, may improve pain control in the emergency department setting and beyond.
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    • "Although increasing opioid prescribing for non-cancer patients may imply better attention to managing unresolved pain (Portenoy, 2004), widespread use of long-term opioids in CNCP has raised safety concerns. Recent studies suggest that long-term opioid use is associated with more frequent emergency department attendances and an increased incidence of side effects (Okie, 2010) and risk of opioid diversion and abuse, overdose and deaths (Gilson et al., 2007). "
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    ABSTRACT: Background This study evaluated the prescribing trends of four commonly prescribed strong opioids in primary care and explored utilization in non-cancer and cancer users.Methods This cross-sectional study was conducted from 2000 to 2010 using the UK Clinical Practice Research Datalink. Prescriptions of buprenorphine, fentanyl, morphine and oxycodone issued to adult patients were included in this study. Opioid prescriptions issued after patients had cancer medical codes were defined as cancer-related use; otherwise, they were considered non-cancer use. Annual number of prescriptions and patients, defined daily dose (DDD/1000 inhabitants/day) and oral morphine equivalent (OMEQ) dose were measured in repeat cross-sectional estimates.ResultsIn total, there were 2,672,022 prescriptions (87.8% for non-cancer) of strong opioids for 178,692 users (59.9% female, 83.9% non-cancer, mean age 67.1 ± 17.0 years) during the study period. The mean annual (DDD/1000 inhabitants/day) was higher in the non-cancer group than in the cancer group for all four opioids; morphine (0.73 ± 0.28 vs. 0.12 ± 0.04), fentanyl (0.46 ± 0.29 vs. 0.06 ± 0.24), oxycodone (0.24 ± 0.19 vs. 0.038 ± 0.028) and buprenorphine (0.23 ± 0.15 vs. 0.008 ± 0.006). The highest proportion of patients were prescribed low opioid doses (OMEQ ≤ 50 mg/day) in both non-cancer (50.3%) and cancer (39.9%) groups, followed by the dose ranks of 51–100 mg/day (26.2% vs. 28.7%), 101–200 mg/day (15.1% vs. 19.2%) and >200 mg/day (8.25% vs. 12.1%).Conclusions There has been a huge increase in strong opioid prescribing in the United Kingdom, with the majority of prescriptions for non-cancer pain. Morphine was the most frequently prescribed, but the utilization of oxycodone, buprenorphine and fentanyl increased markedly over time.
    European journal of pain (London, England) 10/2014; 18(9). DOI:10.1002/j.1532-2149.2014.496.x · 3.22 Impact Factor
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    • "The growing opioid-use epidemic in the U.S. [1] has been associated with a significant increase in the prevalence of Contemporary Clinical Trials 39 (2014) 158–165 ⁎ Corresponding author: Tel.: +1 513 585 8292(office), +1 513 310 0442(cell); fax: +1 513 585 8278. E-mail address: (T. "
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    ABSTRACT: The growing opioid-use epidemic in the U.S. has been associated with a significant increase in the prevalence of pregnant opioid-dependent women and of neonatal abstinence syndrome (NAS), which is caused by withdrawal from in-utero exposure to drugs. While methadone-maintenance currently is the standard of care for opioid dependence during pregnancy, recent research suggests that buprenorphine-maintenance may be associated with shorter infant hospital lengths of stay (LOS) relative to methadone-maintenance. There is no “gold standard” treatment for NAS but there is some evidence that buprenorphine, relative to morphine or methadone, treatment for NAS may reduce LOS and length of treatment. A point-of-care clinical trial (POCCT) design, which maximizes the external validity of a trial while reducing the cost and complexity associated with the classic randomized clinical trial, was selected to compare methadone to buprenorphine treatment for opioid dependence during pregnancy and for NAS. The present paper describes design considerations for the Medication-assisted treatment for Opioid-dependent expecting Mothers (MOMs; estimated N = 370) and Investigation of Narcotics For Ameliorating Neonatal abstinence syndrome on Time in hospital (INFANTs; estimated N = 284) POCCTs, both of which are randomized, intent-to-treat, two-group trials. All outcomes will be obtained from the participants' electronic health record (Epic) from the three participating hospitals. Another novel aspect of the trial design is that a subset of the infants in the INFANTs POCCT will be from mothers who participated in the MOMs POCCT and, thus, the potential interaction between medication treatment of the mother and the infant can be evaluated.
    Contemporary Clinical Trials 08/2014; DOI:10.1016/j.cct.2014.08.009 · 1.99 Impact Factor
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