Opioid Dose and Risk of Road Trauma in Canada:  A Population-Based Study

Gomes reported progressively increasing risks for motor vehicle accidents (MVA's) paralleling opioid dosing from very low to low dose (21% odds) to moderate dose (29%) to high dose (42%) to very high doses (23%), admirably remarking that seemingly confounding inconsistency between very high prescribed dose relative to low MVA events may reflect occult diversion.(1) Very high dose recipients simply may not be at risk for necessarily dose-dependent opioid-induced adverse cognitive impact related MVA's if they are not consuming the entirety of prescribed narcotics. Gomes reported eligibility criterion of the unemployed, disability income-receiving population.  What is perplexing is that very high dosing, if truly consumed, should effect greater pain relief, with discard of pain-related disability and return to full-time work function, obviating inclusion in Gomes' study. 

A unifying hypothesis reasonably explaining the disparate findings is that of diversion. Attentive physicians strive to limit opioid doses, given the recent epidemic of opioid deaths and options to offer compassionate, necessary non-narcotic treatment. Unemployed, very highest dose solicitors viewing opioids as supplemental income may be declaring occult diversion by dosing requests, effectively informing clinicians that they are not viable opioid candidates for reasons of public safety.The epidemic of deaths markedly afflicts the non-patient addict consumer and the source is often diversion. Illegitimate unintended prescription opioid recipients obtain narcotics from non-physicians, such as individuals masking as patients, and constitutes the majority of abusers.(2)   Approximately 40% of deaths occur in individuals abusing opioids obtained through felonious doctor shopping and drug diversion.(3)  If permitted, the clinician is the tool of access. Future research may further substantiate the hypothesis if, relative to lower dose patients, very high dose recipients, preferentially and statistically significantly, solicited hydromorphone or fentanyl, given appreciable diversion value relative to negligible street interest in abuse-resistant opioid products.(4) Similarly, given the considerable abuse mitigation properties of a combination of acetaminophen with oxycodone or acetaminophen with hydrocodone,(5), it would be invaluable to investigate if very high dose recipients preferentially solicited ubiquitously, highly abusable short half-life generic oxycodone bereft of acetaminophen. 

Gomes' study design also should be applied to an employed patient population.Gomes' evidence presents a need for caution and further study as a significant percentage of deaths are diversion related. Gomes indirectly supports that unemployed disability patients soliciting very high dosing may simply not be suffering dose-dependent adverse side effects of opioids or appreciating opioid-conferred objective functional improvement to discard disability as they are diverting their prescriptions.

1. Gomes T, Redelmeier DA, Juurlink DN, et al. Opioid dose and risk of road trauma in Canada. A population based study. JAMA Intern Med. 2013 Feb. 11;173(3):196-201.

2. Huang B, Dawson DA, Stinson FS, et al. Prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug use disorders in the United States: results of the national epidemiological survey on alcohol and related conditions. J Clin Psychiatry 2006 July;67(7):1062-1073.

3. Manchikanti L, Helm S 2nd, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012 Jul;15(3 Suppl):ES9-38. 

4. Cicero TJ, Ellis MS, Surratt HL. Effect of abuse-deterrent formulations of OxyContin. N Engl J Med. 2012 Jul 12;367(2):187-189.

5. Houlton JJ, Donaldson AM, Zimmer L, Seiden A. Intranasal drug-induced fungal rhinopharyngitis. Int Forum Allergy Rhinol. 2012 Mar-Apr;2(2):130-134.