Article

A Flood of Opioids, a Rising Tide of Deaths

Georgetown University School of Medicine, Washington, DC, USA.
New England Journal of Medicine (Impact Factor: 55.87). 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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    • "The sample was selected from patients in the VHA system during fiscal years (October 1 of the prior calendar year to September 30) 2004–2009. Inclusion criteria were: (1) filled an opioid prescription at a VHA facility during the study timeframe; (2) had a chronic pain diagnosis in the medical record[(3)were prescribed to be taking an opioid on the index date (see the Design section above); and (4) started a " new " opioid treatment episode at some point during fiscal years 2002–2009, defined as having an opioid prescription fill after a 2-year (or greater) period with use of VHA treatment services and without an opioid prescription fill. The last criterion was intended to allow sufficient opportunity to measure patient and treatment characteristics from the medical records preopioid treatment to generate matching variables. "
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    ABSTRACT: Background: High opioid dosage has been associated with overdose, and clinical guidelines have cautioned against escalating dosages above 100 morphine-equivalent mg (MEM) based on the potential harm and the absence of evidence of benefit from high dosages. However, this 100 MEM threshold was chosen somewhat arbitrarily. Objective: To examine the association of prescribed opioid dosage as a continuous measure in relation to risk of unintentional opioid overdose to identify the range of dosages associated with risk of overdose at a detailed level. Methods: In this nested case-control study with risk-set sampling of controls, cases (opioid overdose decedents) and controls were identified from a population of patients of the Veterans Health Administration who were prescribed opioids and who have a chronic pain diagnosis. Unintentional fatal opioid analgesic overdose was measured from National Death Index records and prescribed opioid dosage from pharmacy records. Results: The average prescribed opioid dosage was higher (P<0.001) for cases (mean=98.1 MEM, SD=112.7; median=60, interquartile range, 30-120), than controls (mean=47.7 MEM, SD=65.2; median=25, interquartile range, 15-45). In a ROC analysis, dosage was a moderately good "predictor" of opioid overdose death, indicating that, on average, overdose cases had a prescribed opioid dosage higher than 71% of controls. Conclusions: A clear cut-point in opioid dosage to distinguish between overdose cases and controls was not found. However, lowering the recommended dosage threshold below the 100 MEM used in many recent guidelines would affect proportionately few patients not at risk for overdose while potentially benefitting many of those at risk for overdose.
    Full-text · Article · Jan 2016 · Medical Care
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    • "Fatal poisonings, most of which are caused by drug overdose , have increased by nearly 600% in the past three decades and are now the leading cause of injury death in the United States (Warner et al., 2011). This rise was initially driven primarily by deaths attributable to opioid painkillers, which nearly quadrupled between 1999 and 2011 and reached over 16,000 in 2013 (Chen et al., 2014; Modarai et al., 2013; Okie, 2010). The country has also seen a dramatic surge in heroinrelated deaths, which increased by nearly 400 percent between 2000 and 2013 to over 8,000 per year (Chen et al., 2015; Hedegaard et al., 2015; Jones, 2013; Pollini et al., 2011; Rudd et al., 2014). "
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    ABSTRACT: Background: Opioid overdose, which has reached epidemic levels in the United States, is reversible by administration of the medication naloxone. Naloxone requires a prescription but is not a controlled substance and has no abuse potential. In the last half-decade, the majority of states have modified their laws to increase layperson access to the medication. Methods: We utilized a structured legal research protocol to systematically identify and review all statutes and regulations related to layperson naloxone access in the United States that had been adopted as of September, 2015. Each law discovered via this process was reviewed and coded by two trained legal researchers. Results: As of September, 2015, 43 states and the District of Columbia have passed laws intended to increase layperson naloxone access. We categorized these laws into three domains: (1) laws intended to increase naloxone prescribing and distribution, (2) laws intended to increase pharmacy naloxone access, and (3) laws intended to encourage overdose witnesses to summon emergency responders. These laws vary greatly across states in such characteristics as the types of individuals who can receive a prescription for naloxone, whether laypeople can dispense the medication, and immunity provided to those who prescribe, dispense and administer naloxone or report an overdose emergency. Conclusions: Most states have now passed laws intended to increase layperson access to naloxone. While these laws will likely reduce overdose morbidity and mortality, the cost of naloxone and its prescription status remain barriers to more widespread access.
    Full-text · Article · Oct 2015 · Drug and alcohol dependence
    • "In this respect the comment of Paulozzi (CDC) is of interest as he suggested that the higher prescription rates and sales of opioids during the 1990s brought " abusable " drugs into rural areas where the availability of illicit drugs, such as heroin or cocaine, was very low. " Everybody's within a few miles of a pharmacy " , he said, though he admits that increased availability is not the only relevant factor [4]. That misuse of POs interacts with heroin use is corroborated 0 3000 6000 9000 12000 15000 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 "
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    ABSTRACT: In the the past two decades the medical use of prescription opioids (POs), in particular oxycodone, increased up to 14-fold in the U.S. and Canada. The high consumption of these pain relievers also led to non-medical use and abuse of these substances which in turn resulted in a dramatic increase in the number of PO related fatalities and opioid dependent subjects. In the U.S. POs became the second most prevalent type of abused drug (4.5 million abusers; 1.7% of the population) after marijuana (8 million abusers) with currently 1.9 million (0.7% of the population) people dependent on opioid pain relievers. Pain relief was the leading motive for non-medical use in about 40% of the cases, but about half of non-medical PO users reported non-pain relief motives only, like to get high or to relax. Since 2011, there is a decline in the use and misuse of POs and reduction in painkiller overdose deaths in the U.S. probably due to the introduction of a variety of restrictive regulations. In Europe, the medical use of POs is increasing as well, but at a much slower rate than in the U.S. Moreover, in Europe non-medical use of POs and fatal PO incidents are (still) rare. The paper highlights and discusses the differences between Europe versus U.S. and Canada in an attempt to assess the risk of a PO abuse and overdose epidemic in Europe. It is concluded that the risk in Europe seems to be rather limited but vigilance is needed.
    No preview · Article · Jun 2015 · Current Drug Abuse Reviews
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