According to the National Institutes of Health (NIH), more than 18,000 people died from overdoses of prescription opioids in 2014. This is more than the number of overdose deaths attributed to heroin (10,854) and cocaine (5,415) combined. Opioids are pain relievers that are chemically similar to morphine. Existing clinical guidelines recommend against exceeding a threshold of 100 morphine-equivalent mgs (MEMs). Yet the right dosage for a given patient will vary depending on multiple factors and the consequences of missing the target can be fatal. Aside from being easy to remember, the 100 MEM limit provides little clarity or precision, either for physicians or their patients.
To address this issue, Amy Bohnert and colleagues examined the prescribing records of 221 veterans who died from an accidental overdose of prescribed opioids. Their study was published in the May issue of Medical Care. Intentional overdoses and those receiving palliative care were excluded from the analysis. Using data from the Veterans Administration (VA), the 221 cases were matched with an equal number of controls based on numerous characteristics, including a history of substance abuse, depression, long-term use of opioids, and other comorbidities. The study found that the prescribed dosage was about twice as high for cases compared to controls (98 vs 48). Sixty percent of the veterans who overdosed were prescribed more than 50 MEMs per day, compared to less than 25 percent of controls. Amazingly, 69% of fatalities had prescription dosages of 100 MEMs or less per day.
The study has important implications for clinical practice. According to the authors, “Lower prescribed opioid dosages are associated with reduced risk of overdose, but risk is not completely absent at low dosages. More specifically, there is not a threshold below which risk is eliminated, and clinicians should be aware that there are risks of opioid overdose even at lower dosages.”
Dr. Bohnert was also part of the CDC’s task force to develop new clinical guidelines for opioid prescribing. Among their recommendations is to first try other non-opioid approaches to pain management and to use urine drug testing prior to starting treatment. According to the authors, this could significantly reduce the number of overdoses by avoiding escalating dosages for patients with chronic pain. This would also reduce the number of pills in patients’ medicine cabinets. Pills in excess of 50 MEMs could easily prove fatal to children or teenagers who have not developed a tolerance for such high dosages.
While media reports have focused almost exclusively on overtreatment, there is another side to the policy debate that is seldom heard. For more about that, read this moving personal essay by Janice Schuster in Health Affairs about the nightmare of living with chronic pain. She writes that “some clinicians view us with skepticism or disbelief. At times we are reduced to begging for help. Even then, many of us are dismissed as drug-seeking addicts.”
In a perfect world, all patients experiencing pain would receive the exact amount of medication required to alleviate their symptoms and all excess pills would be discarded or vaporized. In the real world, the net loss from the mismatch between dosage and symptoms can result in both overtreatment and undertreatment of pain. More research is needed to understand how to rectify this mismatch and find better pain treatment options.