__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use abuse, enrollment in a methadone maintenance program, cirrhosis, hepatitis, and cocaine use were significantly associated with accidental death. Men- tal illness, previous suicide attempts, chronic pain, and a history of cancer were significantly associated with death by suicide. Methadone hours; the initial recommended dose of 2.5–10 mg was unchanged [6; 99]. In 2008, use of the highest oral dose preparations, 40 mg, was prohibited from use in pain treatment and restricted to addiction therapy [94]. Mortality Risk in Highly Controlled Inpatient Settings
Historically, methadone was used primarily as pharmacotherapy for heroin addiction. During the 1990s, however, methadone gained increased accep- tance for use as an analgesic, and methadone began to be prescribed to outpatients with moderate-to- severe noncancer pain. Prescribing rates soared over the next decade; comparison of methadone sales quantity between 1997 and 2007 shows an increase of 1293% [96; 97]. This rising use of methadone occurred simultaneously with concerns over the abuse potential of OxyContin and the search for a relatively inexpensive long-acting opioid analgesic alternative [98]. By 2008, two-thirds of methadone prescriptions were for pain treatment. The unique pharmaco- logic properties of methadone make its use in pain management complex, with greater potential for hazard than other prescribed opioids. Prescribers familiar with using methadone as opioid addiction treatment may be unaware that suppression of opi- oid withdrawal symptoms lasts 24 or more hours, while the analgesic duration is 4 to 8 hours, despite a half-life exceeding 60 hours in some patients. Acci- dental overdose fatalities can occur when patients re-administer methadone when the analgesia wears off and pain returns, potentially elevating plasma concentrations to life-threatening levels. These same pharmacological properties also imperil those who use it illicitly. Opioid abusers often co-administer benzodiazepines, which greatly elevates lethality risk with methadone. Concurrent use of alcohol poses the same risk [98]. Since the mid-2000s, methadone has become dispro- portionately represented in cases of opioid analgesic fatality. Based on data showing that 70% of fatalities among those prescribed methadone occurred in the first seven days of treatment, the FDA changed the methadone labeling in 2006 to lengthen dosing intervals from every 3 to 4 hours to every 8 to 12
In addition to the well-publicized risk of overdose fatality with prescribed and diverted opioid anal- gesics, it is worth mentioning that use of opioid analgesics carries risk even under the most tightly controlled conditions. In 2012, the Joint Commis- sion released a Sentinel Event Alert entitled “Safe Use of Opioids in Hospitals,” which referenced database reports of death or serious morbidity between 2004 and 2011. Of all events resulting in serious morbidity or mortality, 47% resulted from wrong medication dose errors, 29% resulted from inad- equate patient monitoring, and 11% were due to other factors, including excessive dosing, medication interactions, and adverse drug reactions. Prescriber knowledge deficits in opioid pharmacology and optimum opioid route of administration (e.g., oral, parenteral, transdermal patches) accounted for some of the serious adverse patient outcomes [100]. The Joint Commission findings of serious opioid-related morbidity and mortality even when administered under highly controlled conditions and correlational data that show increased prescription opioid abuse and overdose fatality with increased opioid prescrib- ing suggest that adverse outcomes occur at a fixed ratio to overall use [100]. Chronic Pain and Suicide by Overdose Prolonged intense pain can destroy quality of life and the will to live, driving some patients to suicide [39]. The growing concern over opioid addiction and fatal overdose have obscured the relevant problem of intentional overdose. For many individuals, com- mitting suicide is a way out of a situation or problem causing extreme suffering. According to DAWN, an estimated 228,366 ED visits for drug-related suicide attempts occurred in 2011 [101]. This was a 51% increase in these types of visits in individuals older than 11 years of age compared with 2005 [102]. There was a 58% increase in individuals 18 to 29 years of age, and a 104% increase in those 45 to
23
MDMS1526
Powered by FlippingBook