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Opioid Overdoses: How Do We Balance Help and Harm?

by Dr. Sharon Orrange on February 4, 2016 at 2:03 pm

Opioid pain medication is an emotional topic for everyone. Patients who struggle with chronic noncancer pain and need opioid medications feel they are portrayed as addicts when they ask for refills. Each week I see many patients using opioids for the appropriate reason, who have tried and failed with other medications and yet feel stigmatized by the use of medicine they need.

The flipside, however, is that more and more of us are dying from prescription pain medication overdoses, in addition to heroin overdoses when addicts move from Oxycontin to heroin. Many heroin addicts report their addiction started when a doctor prescribed them an opioid pain medication for something: wisdom teeth, knee surgery, or many other common uses.

You see the struggle here—these medications work when used for the right reason, but can cause massive destruction when it is not indicated.

Alarmingly, a recent study revealed that 91% of patients who were hospitalized for opioid medication overdose were prescribed opioids by their doctor AFTER their overdose. So physicians are largely to blame there, and rightly so.

New prescribing guidelines are being set for opioid pain medications that will lead many to feel frustrated that their doctor “doesn’t want to give them pain meds.” Here are the points on both sides, please weigh in. The struggle is real.

  • What medications are we talking about? Common examples are hydrocodone (Norco, Vicodin), hydromorphone (Dilaudid), and oxycodone (Oxycontin).
  • Set in stone. It is a fact that treatment of chronic noncancer pain with prescription opioids has increased dramatically in recent decades, and so have deaths from overdoses.
  • Overdose. It is also a fact that a recent large study of patients hospitalized for opioid overdose (while using opioids for noncancer pain) found that 2,567 (91%) of them received one or more opioids after overdose. You heard that right? On days 31 to 60 after the overdose, 69% to 71% of patients had an active opioid prescription on any given day. Even in the month after overdose, between 31% and 36% of patients received high-dose daily opioids.
  • The evil twin. It is a fact that using benzodiazepines (Xanax, Ativan, Valium, or their generics) along with opioids increases the risk of overdose. Yet, in the post-overdose period 58% of patients received one or more of benzodiazepine prescriptions. Sadly, this is largely the doctor’s fault.
  • Clear guidelines. Prescribing guidelines for doctors clearly state that misuse of opioids and adverse effects (overdose being THE major adverse effect) are reasons to discontinue opioids. So, are doctors unaware their patients have overdosed, or just still willing to prescribe the opioids anyway?
  • What should doctors be doing? Before starting you on opioid pain medications, your doctor should conduct a physical exam and take your pain history, past medical history, and family/social history. We should consider all treatment options and use opioids only when alternative treatments are ineffective—for example, NSAIDS, muscle relaxants, physical therapy, acupuncture, referral to specialist etc. Physicians must start patients on the lowest effective dose and use much greater vigilance at high doses. Using safe and effective methods for discontinuing opioids (tapering, referrals to medication-assisted treatment, substance use specialists, or other services) is also a must.
  • Lower is better, especially when it comes to opioid pain meds. When doctors did prescribe opioids after overdose events, prescribed dosages were substantially lower than those given in the 90 days before the event—and dosages stabilized at those lower levels, showing that a lower dose was just as effective.
  • Turning overdose into opportunity. Folks hospitalized for conditions related to substance abuse show a readiness to change, so help during and right after hospitalization can turn a potentially devastating event into an opportunity.
  • Haters gonna hate. I prescribe opioid pain medications to my patients but only after we’ve exhausted all other options, because of the destruction they can cause. As a physician and blogger, the most hateful comments I receive will be after articles on non-opioid options for pain control so I’ll expect it again here. Having said that, we can no longer ignore the increasing number of patients taking these medications and the crisis of prescription drug overdose. Weigh in.

Dr O.

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