Patients who take too many opioids often do it twice.
Chances are you have known someone who takes medication for a pain problem. You might assume that if he ever overdosed and ended up in an emergency room, he’d be alarmed enough to cut back or would lose his prescription. Don’t count on it.
Even as overdoses from narcotic prescription painkillers reach record levels in the United States, a large study of insurance claims has found that more than 90 percent of people who survive an overdose get another prescription for an opioid drug like Oxycontin, Vicodin, or Percocet.
"Seventy percent of patients who overdosed were getting their drugs from the same doctor who prescribed the narcotic before the overdose," noted lead researcher Marc LaRochelle, MD, an assistant professor of medicine at Boston University School of Medicine.It’s likely that these doctors didn't even know that their patients had suffered an overdose. Hospitals and insurers don’t automatically send records of overdoses to the prescribing doctor. Many patients apparently aren’t telling their doctors either, or, in 20 percent of the cases, go to a different doctor to get their ‘script. "This signals a problem with the health system, but I don't think it necessarily fingers doctors as being bad doctors," LaRochelle said.
However, in states with a prescription monitoring program, doctors can check the database to see if their patients have had an overdose or are getting prescriptions from several doctors.
You may be surprised to realize just how many Americans take painkillers. In 2012, healthcare providers wrote 259 million prescriptions for opioid pain relievers — enough for every American adult to have a bottle of pills, according to the Centers for Disease Control and Prevention. Sales of prescription opioids have tripled since 1999, although there’s no evidence of an increase (or decrease) in reported pain.
In 2013, more than 16,000 people died in the United States from overdose related to opioid pain relievers, four times the number in 1999.
In the insurance claims study, researchers at Boston Medical Center and Harvard University combed a database covering 50 million people and found nearly 3,000 adults who had an overdose of prescribed painkillers, without dying, over a 12-year period. The study focused on people who were not being treated for cancer pain and were between the ages of 18 and 64. They tracked each one for two years, or until they overdosed again, left their insurance, or turned 65, whichever came first.
First, they checked to see what had happened to the pain patients about 10 months after the overdose. It turned out that 70 percent of the patients had a painkiller prescription from the same doctor and 20 percent from a different doctor. A huge 7 percent had overdosed again — within less than a year. Within two years, 17 percent of the patients with the most generous prescriptions had overdosed again.
LaRochelle says that physicians need to prescribe fewer opiod painkillers, which are often used to control issues like back pain, even though there isn’t good evidence that they’re effective. In an editorial accompanying the study, Jessica Gregg, MD, PhD, a physician at the Portland social-services agency Central City Concern, points out that doctors must rely on patient accounts to judge how much pain they are in — which makes the signs of addiction less clear-cut.
Having a more powerful prescription made you somewhat more likely to overdose twice. Among those with a prescription of more than 60 mg of oxycodone daily or an equivalent, 17 percent had overdosed twice within two years. If your prescription was more moderate — 40 to 60 mg of oxycodone or the equivalent — 15 percent had overdosed a second time; the figure for those with a weaker prescription was 9 percent.
Painkillers can be helpful when you’re recovering from major surgery or injury, but their risks outweigh the benefits if you use them incorrectly or for too long.
Take as little as possible, and stop as soon as you can. Try not to take them longer than a month. Your tolerance will increase, along with your risk of side effects and dependence. After a month, it’s time to talk to your doctor about other options.
Women who are planning to become pregnant should make sure they tell their doctor before accepting a prescription for opioids.
Never combine opioid painkillers with with benzodiazepines (like Ambien or Zanax), which are prescribed for anxiety or insomnia. Both slow the heart and breathing and depress the nervous system while affecting brain function — a potentially lethal combo. Also avoid mixing either one with alcohol or antidepressants, which has the same effects; if you’re taking any of these drugs, it’s safest not to drink alcohol at all. In addition, plan to avoid driving, operating machinery, or performing any complex activity.
March 31, 2020
Christopher Nystuen, MD, MBA