Opioid overdoses in the United States

Opioid Poisoning and Opioid Use Disorder in Older Trauma Patients

Background

Patients hospitalized following a traumatic injury will be frequently treated with opioids during their stay and after discharge. We examined the relationship between acute phase (<3 months) opioid use after discharge and the risk of opioid poisoning or use disorder in older trauma patients.

Methods

In a retrospective multicenter cohort study conducted on registry data, we included all patients ≥65 years admitted (hospital stay >2 days) for injury in 57 trauma centers in the province of Quebec (Canada) between 2004 and 2014. We searched for opioid poisoning and opioid use disorder from ICD-9 to ICD-10 code diagnosis after their initial injury. Patients that filled an opioid prescription within a 3-month period after sustaining the trauma were compared to those who did not, using Cox proportional hazards regressions.

Results

A total of 70,314 admissions were retained for analysis; median age was 82 years (IQR: 75–87), 68% were women, and 34% of the patients filled an opioid prescription within 3 months of the initial trauma. During a median follow-up of 2.6 years (IQR: 1–5), 192 participants (0.27%; 95% CI: 0.23%-0.31%) were hospitalized for opioid poisoning and 73 (0.10%; 95% CI: 0.08%-0.13%) were diagnosed with opioid use disorder. Having filled an opioid prescription within 3 months of injury was associated with an increased hazard ratio of opioid poisoning (2.8; 95% CI: 2.1–3.8) and opioid use disorder (4.2; 95% CI: 2.4–7.4) after the injury. However, history of opioid poisoning (2.6; 95% CI: 1.1–5.8), of substance use disorder (4.3; 95% CI: 2.4–7.7), or of the opioid prescription filled (2.8; 95% CI: 2.2–3.6) before the trauma, was also related to opioid poisoning or opioid use disorder after the injury.

Conclusion

Opioid poisoning and opioid use disorder are rare events after hospitalization for trauma in older patients. However, opioids should be used cautiously in patients with a history of substance use disorder, opioid poisoning or opioid use.

Quantity of opioids consumed following an emergency department visit for acute pain: a Canadian prospective cohort study

OBJECTIVES

Prescription opioid diversion is a significant contributor to the opioid misuse epidemic. We examined the quantity of opioids consumed by emergency department (ED) discharged patients after treatment for an acute pain condition (musculoskeletal, fracture, renal colic, abdominal pain and other), and the percentage of unused opioids available for potential misuse.

DESIGN

Prospective cohort study.

SETTING

Tertiary care trauma centre academic hospital.

PARTICIPANTS

A convenience sample of patients ≥18 years who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day paper diary of daily pain medication use. To reduce lost to follow-up, participants also responded to standardised phone interview questions about their previous 14-day pain medication use.

OUTCOMES

Quantity of morphine 5 mg tablets (or equivalent) prescribed, consumed and unused during a 14-day follow-up. Quantity of opioids to adequately supply 80% of patients for 2 weeks and 95% of patients for the first 3 days was also calculated.

RESULTS

Results for 627 patients were analysed (mean age ±SD: 51±16 years, 48% women). Patients consumed a median of seven tablets of morphine 5 mg (32% of the total prescribed opioids). The quantity of opioids to adequately supply 80% of patients for 2 weeks was 20 tablets of morphine 5 mg for musculoskeletal pain, 30 for fracture, 15 for renal colic or abdominal pain and 20 for other pain conditions. The quantity to adequately supply 95% of patients for the first 3 days was 15 tablets of morphine 5 mg.

CONCLUSIONS

Patients discharged from the ED with an acute pain condition consumed a median of fewer than 10 tablets of morphine 5 mg (or equivalent). ED physicians should consider prescribing a smaller quantity of opioids and asking the pharmacist to dispense them in portions to minimise unused opioids.

TRIAL REGISTRATION NUMBER

NCT02799004; Results.

Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain

Rising overdose fatalities among U.S. veterans suggest veterans taking prescription opioids may be at risk for overdose. However, it is unclear whether veterans prescribed chronic opioids are aware of this risk. The objective of this study was to identify risk factors and determine awareness of risk for opioid overdose in veterans treated with opioids for chronic pain, using veterans treated with methadone or buprenorphine for opioid use disorder as a high-risk comparator group. In the current study, 90 veterans on chronic opioid medication, for either opioid use disorder or pain management, completed a questionnaire assessing risk factors, knowledge, and self-estimate of risk for overdose. Nearly all veterans in both groups had multiple overdose risk factors, although individuals in the pain management group had on average a significantly lower total number of risk factors than did individuals in the opioid use disorder group (5.9 versus 8.5, p < .0001). On average, participants treated for pain management scored slightly but significantly lower on knowledge of opioid overdose risk factors (12.1 versus 13.5, p < .01). About 70% of participants, regardless of group, believed their overdose risk was below that of the average American adult. There was no significant relationship between self-estimate of overdose risk and either number or knowledge of opioid overdose risk factors. Our results suggest that veterans in both groups underestimated their risk for opioid overdose. Expansion of overdose education to include individuals on chronic opioids for pain management and a shift in educational approaches to overdose prevention may be indicated.

Prevalence of chronic non-cancer pain in a UK prison environment

Chronic non-cancer pain (CNCP) is significant global health issue, accounting for a substantial increase in prescription analgesics worldwide, in recent decades. This clinical burden is evident in the UK prison population, where the prevalence of CNCP has never previously been determined. This study, conducted in June/July 2013, used prescribing data and a systematic review of clinical records from two UK prison establishments to derive a figure for point-prevalence of CNCP. Results showed that 20% of the total aggregated prisoner rolls (N = 1944) described CNCP and had been in receipt of treatment with daily analgesia, for a period of at least 3 months prior to observation date. This prevalence of CNCP was related to increasing age group (Spearman's rank correlation 0.94). Of those on continuous analgesic therapy (CAT), 44% were taking continuous opioid therapy (COT) of any sort. Prisoners with a diagnosis of opioid-type drug dependence (OTDD) were more than twice as likely to complain of CNCP and be on continuous medication for it (odds ratio 2.3). The issues relating to CNCP in prisons are discussed. Further research is recommended, identifying factors influencing CNCP prevalence in prisons, and enabling comparisons to CNCP prevalence in the UK general population.