Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________ Women 25 to 54 years of age have the highest rate of ED admission for opioid misuse or abuse, and the greatest risk of prescription opioid fatality occurs in women 45 to 54 years of age. Non-Hispanic white and American Indian or Alaska Native women have the highest mortality risk from prescription opioids, and opioid analgesics are involved in 1 in 10 suicides among women [92]. of these limitations, the results provide a credible counterbalance to previously published figures. Contributory and Risk Factors for Overdose
The reasons for opioid analgesic overdose fatalities are multifactorial and include prescriber behaviors, patient contributory factors, nonmedical use pat- terns, and systemic failures. Risk factors identified for fatal opioid toxicity include [6]: • Prescriber error due to knowledge deficits • Patient nonadherence to medication regimen • Unanticipated medical and mental health comorbidities, including substance use disorders • Co-administration of other CNS-depressant drugs, including alcohol, benzodiazepines, and antidepressants • Sleep-disordered breathing (e.g., sleep apnea) • Body mass index of 30 or greater Additional factors specifically contributing to metha- done fatality include [94]: • Payer policies that encourage or mandate methadone as first-line therapy • Methadone prescribing in opioid-naïve patients • Lack of prescriber knowledge of methadone pharmacology A population-based study examined patterns and characteristics of opioid users in Ontario, Canada, whose cause of death involved opioid toxicity [95]. Between 2006 and 2008, 2,330 drug-related deaths were identified, of which 58% were partially or entirely attributed to opioids. The manner of death was classified by a coroner as accidental (68%), undetermined (16.3%), or suicide (15.7%). Among decedents, at least 7% ingested opioids that were prescribed to friends or a family member; 19% altered the route of administration through injec- tion, inhalation, or chewing a transdermal patch; 3% had been released from incarceration just before their death; and 5% had switched from one opioid to another near the time of death [95]. Differences were found between decedents who died acciden- tally versus suicide. A personal history of substance
Overdose Fatality and Prescribed Opioid Dosage Several studies have reported a positive association between high-dose opioid prescribing and overdose risk. However, these studies utilized methods in design and data analysis that cast doubt on the results, such as failure to control for the possible effect of opioid abuse on overdose outcomes and differences in the indications, formulations, and opioid products in patients prescribed high versus low dosing [93]. A study was conducted to re-examine the relation- ship between opioid dose and overdose risk while controlling or eliminating the methodological shortcomings in previous studies. The records of 38,861 patients prescribed morphine ER, trans- dermal (patch) fentanyl, or buprenorphine patch between 2005 and 2010 were evaluated. High-dose was defined as 120 mg morphine equivalent dose (MED) or more; low-dose included 30 mg MED or less. The rates of overdose were 0.7% with mor- phine ER, 0.4% with fentanyl patch, and 0.3% with buprenorphine patch. The relative risk of overdose among patients prescribed high doses was 1.44 for morphine ER, 1.51 for fentanyl patch, 0.78 for buprenorphine patch, and 1.18 when all three opioids were combined. These results indicate a roughly 1.5 times greater overdose risk with high- dose morphine and fentanyl than with low-dose, no difference in overdose risk between high- and low-dose buprenorphine, and an overall overdose risk markedly lower than previous reports [93]. This data should be considered tentative as it was presented at a conference and, as of 2023, has not yet been published in a peer-reviewed journal. As with the previous research, this study was performed retrospectively and not prospectively, which can lessen the validity of the results. However, in light
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