Exploring opioid deaths in chronic pain patients

Research has found that over half of patients who died from an opioid overdose had been diagnosed with chronic pain and many had psychiatric disorders. The study was conducted by researchers at Columbia University. According to the U.S. Centers for Disease Control, the number of opioid-related deaths has quadrupled in recent years, from 8,048 in 1999, to 33,091 in 2015, and the researchers were interested in learning more about what lead those patients to take opioids.

The researchers analyzed clinical diagnoses and filled medication prescriptions for 13,089 adults in the Medicaid program who died of an opioid overdose from data collected between 2001 and 2007. During the last year of life, more than half of these adults (61.5%) had been diagnosed with chronic pain and many had also been diagnosed with depression and anxiety. This included 59.3% who were diagnosed with back pain, 24.5% with headaches, and 6.9% with neuropathies. A total of 42.2% of those who died had been diagnosed with a drug use disorder in the year prior to death. However, 4.2%  had been diagnosed with opioid use disorder in the month prior to death and 12.3% with a substance use disorder.  In the year before death, 66.1% filled opioid prescriptions and 61.6% filled benzodiazepine prescriptions, and 50.2% had filled prescriptions for both types of medications. Such a medication combination increases the risk of respiratory depression, where there is slow and shallow breathing that is the primary contributor of death in fatal opioid overdoses.  In the year before death, 59.0% filled prescriptions for antidepressants, 31.6% filled prescriptions for antipsychotics, and 35.4% filled prescriptions for mood stabilizers.

The researchers feel that the frequent occurrence of chronic pain and mental health conditions among overdose deaths shows the importance of offering substance use treatment services in clinics where patients with chronic pain and mental health problems are treated. This might help increase early clinical intervention in patients who are at high risk for fatal opioid overdose. In addition, improving treatment retention with contingency management or other effective behavioral interventions might help lower the risk of fatal overdose in these patients. The authors feel doctors should restrict the combination of both opioids or benzodiazepines to patients where alternative treatments may be effective and also to prescribe the lowest possible dose and duration as needed.

The researchers also note that the study included data over a decade old and in the years since, there has been an increase in the proportion of U.S. overdose deaths involving opioids or benzodiazepines. The study also has a potential for misclassification of opioid-related overdoses, though the ICD-10 classification scheme is consistent with consensus recommendations. In addition different results might have been found if privately insured and uninsured opioid-related fatal overdoses were included in the analysis instead of just using Medicaid program participants.

Note that some dental deaths have occured when combining opioids and benzodiazepines, such as Fentanyl (an opioid) with Midazolam (a benzodiazepine). See http://www.teethremoval.com/dental_deaths.html /.

Source: Mark Olfson, and et al., Service Use Preceding Opioid-Related Fatality, American Journal of Psychiatry, 2017.

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