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Longer-term, high-dosage opioid use an ongoing danger

Longer-term, high-dosage opioid use an ongoing danger

As managers of workers compensation struggle with claims costs linked to abuse of opioid painkillers, researchers are seeking better metrics to quantify dosages that are safe.

Public health officials have long suspected that a high daily morphine equivalent dosage of prescribed opioid analgesics increases the risk of dying from a drug overdose.

For example, Washington state medical treatment guidelines, often considered a benchmark in the workers comp industry, recommend that doctors not increase opioid dosage beyond an average daily morphine equivalent of 120 milligrams to curb the risk of addiction or overdose.

Now, a study in the April issue of the Journal of Pain finds that patients who maintain a high daily level of at least 100 milligrams per day of opioids over periods of up to six months are at greater risk than patients taking high levels of the drugs but for shorter time periods.

“Assessing Risk for Drug Overdose in a National Cohort: Role for Both Daily and Total Opioid Dose?” finds that the sum of opioids ingested over time are an important metric in addition to the daily morphine equivalent dosage.

“The mean daily dose of opioid analgesics has been widely used to assess the risk of overdose death and reported to be greatest for a morphine equivalent dose at least 100 to 120 milligrams per day,” the study states. “However, the total dose of filled opioid prescriptions over a period of time may offer a complementary measure of risk to that provided by the daily MED.”

What dosage is safe?

Joseph Paduda, president of Madison, Connecticut-based pharmacy benefit manager consortium CompPharma L.L.C., said the study correlates with the comp industry's increasing awareness that it's hard to quantify whether there's a dosage for narcotics that isn't harmful.

“We really don't know what a 'safe' dosage is, and it's highly likely that what is a safe dosage for one person is not a safe dosage for somebody else who has a different profile,” Mr. Paduda said.

Mr. Paduda said the study brings into question the wisdom of placing people on long-term opioid prescriptions for chronic pain unless their pain is lessening and their function is improving.

“What we really need to do is ask the question: Should this person be on opioids in the first place?” he said. “Only once we've verified through evidence-based guidelines that it makes sense should we start having the discussion about MEDs.”

Likewise, Dr. Peter Luongo, Pittsburgh-based executive director of the Institute for Research, Education and Training in Addictions, said that while opioids are useful for acute pain, people's tendency to develop a tolerance during long-term usage makes such drugs ill-suited for treating chronic pain.

“One of the insidious things about opioids is that you hit a ceiling and need more dosage just to maintain the same effects,” Dr. Luongo said. “That's the overriding problem with using them for chronic pain.”

Accordingly, the authors of the study suggest that health providers closely monitor total dose of prescribed opioids over a six-month period.

“With increasingly widespread prescription-monitoring programs, it may be feasible to calculate both daily and total dose to help clinicians and other providers to address the risk of drug overdose,” the study states.

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