Opioids: Total and Daily Dose Both Indicators of Overdose Risk

Barbara J Turner MD, MSEd, MA, MACP James D and Ona I Dye Professor of Medicine Director, Center for Research to Advance Community Health (ReACH) University of Texas Health Science Center San AntonioMedicalResearch.com Interview with:
Barbara J Turner MD, MSEd, MA, MACP

James D and Ona I Dye Professor of Medicine
Director, Center for Research to Advance Community Health (ReACH)
University of Texas Health Science Center San Antonio

Medical Research: What is the background for this study? What are the main findings?

Dr. Turner: Daily dose of opioid analgesics has been widely used to assess the risk of overdose death and this risk has been reported to be greatest for a morphine equivalent dose at least 100 to 120 mg per day. However, the total dose of filled opioid prescriptions over a period of time may offer a complementary measure of the risk to that provided by the daily dose. In fact, the total dose is not necessarily a simple linear transformation of the daily dose because not all patients use opioids every day, instead it reflects the total amount of opioids available to a patient.

Among 206,869 national HMO patients aged 18-64 with non-cancer pain filling at least 2 schedule II or III opioid analgesic prescriptions, the rate of overdose was 471 per 100,000 person-years. Over the study period of 3.5 years, risk of drug overdose was two to three times greater for patients with a daily dose >100 mg regardless of the total dose filled or a daily dose of 50-99 mg with a high total dose (>1830 mg) filled a six month interval (versus no opioids). The overdose risk was increased slightly for 50-99 mg per day with a lower total dose and not increased at all for daily doses under 20 mg regardless of the total dose.

Medical Research: What should clinicians and patients take away from your report?

Dr. Turner: Most clinicians are aware of the increased risk of overdose and other complications when patients receive daily opioid doses of >100 mg and many policymakers recommend that these patients be referred to pain specialty care. However, we found that the risk of overdose was also increased by several fold for patients who received more commonly prescribed daily doses (50-99 mg) if they filled a total dose >1830 mg within a 6 month period. This means that if the patient fills a second 30 day prescription for commonly prescribed pain medication such as 6 tabs of 10-325 mg hydrocodone/APAP per day (daily dose of 60 mg) their risk for overdose increases significantly. Thus, clinicians should consider total dose to assess risk of overdose in addition to the daily dose.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Turner: Although our study cohort is national, it involves a younger, commercially insured population. Future studies need to validate the results in diverse populations. If confirmed, studies need to be conducted to help clinicians monitor the total dose of opioids being filled by a patient and to reduce the risk for drug overdose in persons receiving only moderately high doses of opioids.

Citation:

Assessing Risk for Drug Overdose in a National Cohort: Role for Both Daily and Total Opioid Dose?
Liang, Yuanyuan m Barbara J. Turner, M.D., M.S.Ed.
The Journal of Pain
November 11, 2014; Published Online: December 05, 2014
DOI: http://dx.doi.org/10.1016/j.jpain.2014.11.007

 

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