Most who OD on opioids are able to get new prescriptions
More than 90 percent of people who survived a prescription opioid overdose were able to obtain another prescription for the very drugs that nearly killed them, according to a Boston Medical Center study of chronic pain treatment published Monday.
Amid nationwide alarm over soaring overdose deaths, the study in the Annals of Internal Medicine is believed to be the first to ask: What happens to those who survive?
The answer, in the view of lead author Marc R. Larochelle, is stunning.
“Ninety-one percent got another prescription for an opioid,” said Larochelle, an internal medicine physician. “It wasn’t because they went down the street and found a new doctor. Seventy percent got it from the doctor who had prescribed before the overdose.”
Larochelle speculated that the doctors writing those prescriptions didn’t know about the overdose.
The findings suggest major gaps in communication, education, and oversight that persist despite widening concern about the overuse of opioid painkillers, specialists said.
“It really sends an important message about the importance of communication around patients’ treatment needs across different sectors of the medical system,” said Colleen Barry, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. Overdoses can be crises that inspire change, Barry said, but “this article suggests that might not be happening.”
Dr. Jessica Gregg, author of an editorial accompanying the study, said her initial reaction was to think the doctors were lazy or incompetent for prescribing opioids to patients who had overdosed. But in fact, the doctors work in a system that virtually guarantees they will make such errors, because there is no comprehensive mechanism to alert doctors when a patient overdoses, said Gregg, who is addictions medical director of a Portland, Ore., clinic.
At the same time, Gregg wrote in the editorial, “Most providers receive little training, have few resources, and receive minimal support to address either chronic pain or addiction.”
Robert N. Jamison, chief psychologist at the Brigham and Women’s Hospital Pain Management Center, said he wasn’t surprised by the study’s findings, although he considers them an important “heads-up.”
“These are people who have probably been taking narcotics for five, 10 years. To stop completely would be a challenge,” he said. “Then, they’re still left with terrible pain. . . . Clinicians are always struggling with how to manage these people who are just really miserable and suffering.”
Last year in Massachusetts, more than 1,200 people died after overdosing on prescription drugs or on street narcotics such as heroin. The number who die from overdoses is “the tip of the iceberg,’’ Larochelle said, and the number of survivors is many times greater.
To learn more about those survivors, Larochelle and his team plunged into a national database of insurance claims for 50 million people filed between 2000 and 2012. They identified 2,848 patients ages 18 to 64 receiving opioids for pain — not including cancer pain — who survived an overdose, and examined the prescriptions they received two months before and up to two years after the overdose.
The researchers found that in the week before patients suffered overdoses, painkiller dosages increased sharply, suggesting a worsening of pain or cravings. Just over half were also taking tranquilizers.
After the overdose, about 10 to 15 percent discontinued opioids for a time, but even most of those patients ended up with another prescription three months later. One-third of all patients who overdosed continued on very high doses. And 7 percent overdosed again.
Because the data were limited to insurance claims, the study had no information on people without insurance or covered by Medicaid, Medicare, or the Veterans Health Administration. The data also don’t track medications paid for in cash, including those purchased illegally — although many addicted to street drugs started out with drugs that were prescribed.
The data could not answer why people overdosed and yielded little information about whether patients received treatment for addiction.
Physicians may have no way of knowing that their patients overdosed unless the patient volunteered the information, which many would be reluctant to do, Larochelle said. In his own practice, he said, he would find out if his patient’s overdose was treated at Boston Medical Center, but not if the patient was taken to another hospital.
The study suggests several ways to address the problem. The prescription monitoring programs that most states have established to track addictive drugs could be revised to include information on overdoses. Insurance companies could alert physicians when they receive a claim for overdose treatment, or require prior authorization for any opioid prescription written after an overdose.
But doctors also need better education and support, Larochelle said. Among those prescribing opioids, “most are doing it in a very good faith effort to reduce pain, relieve suffering, and doing what’s right for the patient,” he said. “We need to help clinicians be able to do their jobs better.”
There is no evidence that opioids are effective in treating chronic pain, yet many patients say they depend on the drugs to function, Larochelle said. “The easiest thing to do is just refill the prescription,” he said. “The hardest thing to do is sit down and have these long conversations about what to do.”
Gregg, the editorial author, said pain and addiction are time-consuming, chronic diseases that often occur simultaneously.
“There’s not a quick fix,” Gregg said. “But there are slow fixes. Our health systems aren’t particularly well set up for those slow fixes — yoga, physical therapy, addressing trauma — the things that will help, but not quickly.”