Study finds prescribing opioids in smaller amounts reduces overdoses

Sunday, February 7, 2016 - 6:28pm

Giving patients smaller doses of prescription opioid painkillers may prevent overdoses, according to a recent University study.

Opioids, medications often used to treat acute pain from surgeries and cancer, have also increasingly been used in more recent years for chronic pain management.

Amy Bohnert, lead author of the study and assistant professor of psychiatry, said the Center for Disease Control and Prevention’s guidelines for prescription opioid medication have recently begun to suggest lower thresholds than they have in the past. The current guidelines from the CDC have not recommended not going above 90 morphine-equivalent milligrams, also called MEM, and encourage health care providers to be caution once a patient begins to receive or go above 50 MEM, according to Bohnert.

Additionally, the study found the average doses of prescription opioids were much higher for those who died of an overdose as compared to those who survived.

“We found that there was a substantial portion of the people who died in an opioid overdose,” Bohnert said. “Assuming that the fact that they were given such large quantities influenced the fact that they overdosed, had their treatment pattern been different, had they gotten a lower dosage, it could have prevented their death.”

Bohnert said the study stemmed from the results of an original study she worked on five years ago. In that study, Bohnert said the researchers looked at the amount of opioids prescribed to specific patients and how that related to their risk of overdosing on those medications. Bohnert said they found the greater the amount a patient was prescribed, the greater their risk of overdose.

The study used date from the the Veterans Affairs Ann Arbor Healthcare System is a national leader when it comes to having the type of medical records necessary for this research, and is why she decided to complete her research using their resources. The VA is also working with the CDC to have a complete match on cause-specific mortality data.

“We found that the rate of unintentional overdose, by any substance, not just prescription opioids, is twice as high in VA patients than it is in the general population, after you account for differences in age and sex.”

According to the CDC, the rate of deaths from drug overdoses, specifically overdoses involving opioids, has increased 200 percent since 2000.  

Each day, 46 people die from an overdose of prescription opioid or narcotic painkillers in the United States, the CDC also reported. In 2012, reportedly 259 million prescriptions for painkillers were written by health care providers, equaling enough for every American adult to have a bottle of the medication.

Bohnert said the findings that there have been more prescription opioid overdoses recently than in previous years has resulted from changes in the way prescription opioid medication has been used, as the medication is now applied to both acute and chronic pain.

In the study, the researchers changed the design from the original study Beohnert conducted five years ago, she said. Rather than taking an entire population of patients who were prescribed opioids, she said the researchers looked at patients who were identified as having died of a prescription opioid overdose, and were being prescribed opioids at the time that they died.

The researchers then created a comparison group, whose members were matched to patients in the original study basedon criteria such as demographics, clinical characteristics and treatment characteristics.

“What you’re prescribed as a patient should be tailored to what your needs are and the way in which you are unique, so hopefully by matching like we did, we’re making a much more accurate comparison,” Bohnert said. “By doing that, we still found that there were substantial differences between people in terms of opioid doses, between people who died of an overdose and their matched comparison group.”

While the average dose for people who died of an overdose was almost 100 MEM, in the comparison group with patients who did not die of an overdose, the average dose prescribed was less than 50 MEM.

Bohnert said there is additional preview data supporting the idea that if a patient is prescribed a higher dose of a prescription opioid medication, they are more likely to develop problems with the substance, which could lead to risky patterns of behavior associated with the substance that could lead to overdose, Bohnert said.

Additionally, because patients often develop tolerance when they use opioids, they have to use more of the medication to feel the same effects. As a patient gets to higher doses, they can also develop tolerance to the medication’s respiratory depression effects, she noted, a patient has to use more medication to cause an overdose, and maybe prescribed higher doses. As a result of their growing tolerance, they are more likely to have received more medication. 

With more on hand, it is much easier to overdose, Bohnert said.

“The solution to this is going to require a lot of different interventions,” Bohnert said. “One of them is that prescribers are becoming increasingly cautious about escalating doses to higher levels.”

However, Bohnert said that does not address how to help patients who are already on high doses and exhibiting signs showing they are at risk for adverse outcomes with the medications.

Bohnert said there have already been programs to help decrease these patients’ dosages, but that there needs to be more research done to understand how to learn how these programs might dangerously impacts the patients’ risk for bad outcomes.

She noted there is some controversy about whether other medications are better or should be recommended over opioids. However, there are risks to patients taking nonsteroidal anti-inflammatory drugs, common pain-relieving drugs, as well, she said. Many non-pharmacological options, such as physical therapy and cognitive-behavioral therapy, for pain that overall have less risks and future research could be focused, she added.