Increased recognition of pain as the 'fifth vital sign' by the medical profession, direct to consumer advertisement by pharmaceutical companies, and self-advocacy on the part of patients themselves has likely led to the perfect storm: a vastly increased number of prescriptions for opioid medications, and a 124% increase in the rate of unintentional opioid-related overdose death between 1999 and 2007. That's quite of bit of unintentional death, as reported in this week's JAMA.
What exactly is an opioid? As Rick points out in this week's podcast, an opioid is a drug that binds to receptors for such chemicals found on some of the cells in our bodies. The earliest known of this very effective class of pain relievers is opium, derived from the opium poppy. Common opioids in use today include codeine and morphine. These drugs work not just by decreasing our perception and reaction to pain, but by increasing our tolerance for pain as well.
Prescriptions for opioid medications have surged to the hundreds of millions in the United States annually, including a substantial number for those 10 to 21 years of age. This study looked at a Veteran's Administration database from 2004 to 2008, with close to 6 million individuals treated. Of this number almost 32% were treated with opioid medications for pain but were not part of palliative or hospice care. 1136 people died of a prescription opioid overdose during this period, of whom 752 were treated with a prescription opioid for pain between 2004 and 2008.
What factors were related to the risk of death from unintentional overdose? Those who died were more likely to be middle-aged and white, more likely to have acute or chronic pain, have a substance use disorder or other psychiatric diagnosis, and were less likely to have cancer.
In people with cancer the study found that taking opioids only when needed as compared to a regularly scheduled dose of the medication resulted in higher risk of unintentional death. The study also found that the higher the prescribed dose of an opioid the greater the risk of overdose.
Does this study as well as data from the CDC establishing the rather sobering and growing rate of addiction to prescription narcotics in the US point to a need to regulate these medications more strictly? Perhaps not, but as Rick points out in the podcast, other strategies for pain relief should be employed first, including but not limited to NSAIDs, physical therapy, exercise, meditation, and perhaps tai chi. Opioids are among the most effective pain relief agents we have and should be used for that purpose, but both physicians and patients must be aware of their cost/benefit ratio and become educated in their use.
Other topics this week include a way of repairing a heart valve through the skin in NEJM, another pan for PSA testing in BMJ, and self-monitoring of blood thinning medications in Annals of Internal Medicine. Until next week, y'all live well.