Is it Time to Revise Opioid Prescribing Guidelines (Again)?

Study results published in the August issue of Medical Care indicate that opioid overdoses appear to frequently occur in patients who are not chronic users with high prescribed doses of opioids, in contrast to the patient groups targeted by current opioid prescribing guidelines.

“It may be prudent to revise guidelines to also address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use, in addition to chronic, high-dose use,”said study lead author Deborah Fulton-Kehoe, PhD, a research scientist in the Department of Environmental and Occupational Health Sciences at the University of Washington School of Public Health. Targeting prescription sedatives should possibly be another consideration of guidelines, as they were found to be involved in nearly one-half of opioid overdoses.

For the study, Fulton-Kehoe and colleagues sought to examine changes in methadone and other opioid poisoning rates following implementation of the Washington State Opioid Guideline in 2007. The guidelines were introduced in response to the ongoing opioid epidemic and emphasize the high risk of overdose in chronic users with high prescribed opioid doses.

The team also wanted to examine the prescription history before 2,250 non-fatal overdoses among 1,809 patients with at least one paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and an emergency department or inpatient hospital claim for an opioid poisoning. Previous studies have shown that both fatal and nonfatal overdoses are more likely to occur in chronic opioid users and those with higher prescribed opioid doses.

Yet, only 44% of patients with opioid overdoses in the current study were chronic users, defined as having more than a 90-day supply of prescribed opioid medications in the prior year. Just 17% of patients had an opioid dose in the week before their poisoning that would have been the target of opioid prescribing guidelines: a morphine-equivalent dose of more than 120 mg/day, whereas 28% of overdose patients had a morphine-equivalent dose of less than 50 mg/day.

The study investigators also found that about 35% of poisonings were associated with methadone, with the remaining 65% of overdoses due to other opioid medications. For poisonings caused by either, nearly half of patients also had a sedative prescription at the time of their overdose.

“Opioid guidelines and other education interventions will need to be developed to address the opioid poisonings occurring among these patients,” wrote Fulton-Kehoe and colleagues. They also call for strategies targeting patients with prescriptions for sedatives.

“The topic of overdose from prescription opioid medication is a current national crisis,” commented Jeroan J. Allison, MD, MS, a professor in the Department of Quantitative Health Sciences at the University of Massachusetts Medical School, and Co-Editor-in-Chief of Medical Care. “The statistics are quite overwhelming and dramatic, and this problem affects every state in our nation.”

Allison added that although the study was localized to the state of Washington, the findings have national and even global implications. “Namely, the article notes that many overdoses occur when patients are prescribed medications at low doses,” he said. “This has important implications for national policy and debate.”