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Original Investigation |

High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths

Jane A. Gwira Baumblatt, MD1,2; Caleb Wiedeman, MPH3; John R. Dunn, DVM, PhD3,4 ; William Schaffner, MD3,4 ; Leonard J. Paulozzi, MD, MPH5; Timothy F. Jones, MD3
[+] Author Affiliations
1Epidemic Intelligence Service, Centers for Disease Control and Prevention, Tennessee Department of Health, Nashville
2currently with Agency for Healthcare Research and Quality, Rockville, Maryland
3Tennessee Department of Health, Nashville
4 Department of Preventive Medicine and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
5Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, Georgia
JAMA Intern Med. 2014;174(5):796-801. doi:10.1001/jamainternmed.2013.12711.
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Importance  From January 1, 2003, through December 31, 2010, drug overdose deaths in Tennessee increased from 422 to 1059 per year. More of these deaths involved prescription opioids than heroin and cocaine combined.

Objective  To assess the contribution of certain opioid-prescribing patterns to the risk of overdose death.

Design, Setting, and Participants  We performed a matched case-control study that analyzed opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 1, 2007, through December 31, 2011, to identify risk factors associated with opioid-related overdose deaths from January 1, 2009, through December 31, 2010. Case patients were ascertained from death certificate data. Age- and sex-matched controls were randomly selected from among live patients in the TNCSMP.

Main Outcomes and Measures  We defined a high-risk number of prescribers or pharmacies as 4 or more per year and high-risk dosage as a daily mean of more than 100 morphine milligram equivalents (MMEs) per year. The main outcome was opioid-related overdose death.

Results  From January 1, 2007, through December 31, 2011, one-third of the population of Tennessee filled an opioid prescription each year, and opioid prescription rates increased from 108.3 to 142.5 per 100 population per year. Among all patients in Tennessee prescribed opioids during 2011, 7.6% used more than 4 prescribers, 2.5% used more than 4 pharmacies, and 2.8% had a mean daily dosage greater than 100 MMEs. Increased risk of opioid-related overdose death was associated with 4 or more prescribers (adjusted odds ratio [aOR], 6.5; 95% CI, 5.1-8.5), 4 or more pharmacies (aOR, 6.0; 95% CI, 4.4-8.3), and more than 100 MMEs (aOR, 11.2; 95% CI, 8.3-15.1). Persons with 1 or more risk factor accounted for 55% of all overdose deaths.

Conclusions and Relevance  High-risk use of prescription opioids is frequent and increasing in Tennessee and is associated with increased overdose mortality. Use of prescription drug–monitoring program data to direct risk-reduction measures to the types of patients overrepresented among overdose deaths might reduce mortality associated with opioid abuse.

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Figure 1.
Number of Patients Receiving Opioid Prescriptions by Prescribers and Pharmacies Dispensing Prescriptions

A, Patients receiving opioid prescriptions from prescribers. Each year patients with fewer than 4 prescribers account for more than 90% of the total patients (mean, 1.9 million per year). B, Patients receiving opioid prescriptions from pharmacies. Each year patients with fewer than 4 pharmacies account for more than 95% of the total patients (mean, 1.9 million per year).

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Figure 2.
Association of Number of Prescribers and Pharmacies With Risk of Unintentional Opioid Analgesic–Related Overdose Death

Reference was patients receiving opioids from 1 pharmacy or prescriber. Error bars indicate 95% CIs.

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Figure 3.
Association of Mean Daily Dosage of Opioid Analgesics With Risk of Unintentional Opioid-Related Overdose Death

Reference was patients receiving a mean of less than 20 morphine milligram equivalents (MMEs) per year. Error bars indicate 95% CIs.

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Submit a Comment
High dose opioid treatment
Posted on August 14, 2014
Louis Ogden
Chronic & centralized pain patient
Conflict of Interest: None Declared
I have suffered agonizing pain beginning in childhood and up until I was in my early 60s and for almost 4 years I've been on an ultra-high dose opioid therapy (note: I have a defective gene that keeps me from metabolizing well). Simply stated, I have had my highest quality of life since I started this treatment. I will NEVER be able to understand why this is so controversial nor why the debate ALWAYS centers on abuse. IMO, these drugs are safe when used as directed as they do not damage organs, etc. yet I am constantly scrutinized, been called a drug addict to my face by health professionals & others, and many more indignities. This treatment has saved my life as I was thinking suicide after 50+ years of suffering yet it is as if I am GUILTY of something and must prove my innocence - contrary to our Constitution. I do not misuse nor do I sell my medicines but it is a constant fight!
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