Doctors nudged by overdose letter prescribe fewer opioids

Nudging clinicians toward better opioid prescribing. Credit: USC Schaeffer Center for Health Policy & Economics

In a novel experiment, doctors got a letter from the medical examiner's office telling them of their patient's fatal overdose. The response: They started prescribing fewer opioids.
Other doctors, whose patients also overdosed, didn't get letters. Their opioid prescribing didn't change.
More than 400 "Dear Doctor" letters, sent last year in San Diego County, were part of a study that, researchers say, put a human face on the U.S. opioid crisis for many doctors.

12 aug 2018--"It's a powerful thing to learn," said University of Southern California public policy researcher Jason Doctor, lead author of the paper published Thursday in the journal Science.
Researchers used a state database to find 861 doctors, dentists and others who had prescribed opioids and other risky medications to 170 people who died of an overdose involving prescription medicines. Most states have similar databases to track prescribing of dangerous drugs, where doctors can check patients' previous prescriptions.
Most of the deaths involved opioid painkillers, many taken in combination with anti-anxiety drugs. On average, each person who died had filled prescriptions for dangerous drugs from five to six prescribers in the year before they died.
Half the prescribers received letters that began: "This is a courtesy communication to inform you that your patient (name, date of birth) died on (date). Prescription drug overdose was either the primary cause of death or contributed to the death."
The letters offered guidance for safer prescribing. The tone was supportive: "Learning of your patient's death can be difficult. We hope that you will take this as an opportunity" to prevent future deaths.
Then the researchers watched what happened over three months.
Letter recipients reduced their average daily opioid prescribing—measured in a standard way, morphine milligram equivalents—by nearly 10 percent compared to prescribers who didn't get letters. Opioid prescribing in the no-letter group didn't change.
Recipients put fewer new patients on opioids than those who didn't get letters. They wrote fewer prescriptions for high-dose opioids.
The strategy is original, helpful and could be duplicated elsewhere, said pain medicine expert Dr. David Clark of Stanford University, who wasn't involved in the study. He was surprised the letter's effect wasn't larger.
"It may have been easy for physicians to feel it was somebody else prescribing who got the patient in trouble," Clark said, adding that changing even one patient's care takes time, requiring "very difficult conversations."
Opioid prescribing has been declining in the U.S. for several years in response to pressure from health systems, insurers and regulators.
Yet deaths keep rising. Nearly 48,000 Americans died of opioid overdoses last year, according to preliminary numbers released last month, a 12 percent increase from a year before.
Now illegal fentanyl, another opioid, is the top killer, surpassing pain pills and heroin. Lead author Doctor said reducing the number of prescribed opioids will, over time, close off a gateway to illicit drugs by shrinking the pool of dependent people.
The study didn't analyze whether the deaths were caused by inappropriate prescribing or whether the prescribing changes resulted in patients doing better or worse.
That's a flaw in an otherwise careful study, said addiction researcher Dr. Stefan Kertesz of University of Alabama at Birmingham, who has raised red flags about policies that cause doctors to take patients off opioids too fast and without a plan for treating addiction.
Patients can fall into despair or contemplate suicide if they are involuntarily tapered off opioids without support, he said.
"What actually happens to patients should be our concern, rather than just making a number go down," Kertesz said.
Study co-author Dr. Roneet Lev, chief of emergency medicine at Scripps Mercy Hospital in San Diego, discovered her own name in the data.
Lev prescribed 15 opioid pain pills to an ER patient with a broken eye socket, without knowing the patient got 300 painkillers from another doctor a day earlier. Lev didn't get a "Dear Doctor" letter because the patient's death fell outside the timeline of the study, July 2015-June 2016.
Still, she felt the impact and believes she could have done better. Said Lev: "It was an opportunity to look at all the records on that patient and say, 'Wow, I'm really worried about you.'"

More information: J.N. Doctor el al., "Opioid prescribing decreases after learning of a patient's fatal overdose," Science (2018). science.sciencemag.org/cgi/doi … 1126/science.aat4595

© 2018 The Associated Press. All rights reserved.

Opioids linked to higher risk of pneumonia in older adults

Opioids -- a class of medicines commonly given for pain -- were associated with a higher risk of pneumonia in a study of 3,061 adults, aged 65 to 94, e-published in advance of publication in the Journal of the American Geriatrics Society. The study from researchers at Group Health Research Institute and the University of Washington (UW) also found that benzodiazepines, which are drugs generally given for insomnia and anxiety, did not affect pneumonia risk.

23 sept 2011--"Pneumonia is a common infection that can have serious consequences in older adults," said study leader Sascha Dublin, MD, Ph.D, a Group Health Research Institute assistant investigator and Group Health primary care physician.

"Opioids and benzodiazepines work in different ways, but both can decrease the breathing rate. Both are also sedatives, which can increase the risk of aspiration." Aspiration is inhaling material (including saliva or food particles) from the mouth into the lungs, which can lead to pneumonia.

A 2009 study estimated that two million Americans age 65 and older received long-term opioid treatment for non-cancer pain. Prescription opioid use has been on the rise in the United States. In earlier Group Health research, the use of chronic opioid therapy for chronic non-cancer pain doubled in the prior decade. And a 1998 report found that one in 10 older Americans used benzodiazepines.

"In animal studies, some opioids -- including morphine, codeine, and fentanyl -- harm the immune system, which also might contribute to pneumonia," said Dr. Dublin. She and her research team hypothesized that risk of pneumonia would be higher in people using opioids or benzodiazepines than in people not using these medications, and would be highest for opioids that suppress the immune system. Study subjects were members of Group Health Cooperative, a nonprofit health care system with extensive computerized pharmacy, laboratory, and medical records that were used in the analysis.

Dublin and colleagues conducted a "case-control study," matching patients who had pneumonia during the study period of 2000 to 2003 ("cases") with similar patients who did not have pneumonia ("controls"). All were living in the community, not hospitalized or in nursing homes, and the researchers excluded people whose immune systems were suppressed.

The researchers measured whether people with pneumonia were more likely than controls to have taken opioids or benzodiazepines before the start of their illness. Among pneumonia cases, 13.9 percent were using opioids and 8.4 percent were using benzodiazepines. In subjects without pneumonia, 8.0 percent were using opioids and 4.6 percent were using benzodiazepines.

Statistical analysis by the researchers showed that:

• Patients taking long-acting opioids such as sustained-release morphine were more than three times as likely to get pneumonia as were those not taking opioids.
• Recently starting use was a risk factor: During their first 14 days of use, patients who took opioids were more than three times as likely to get pneumonia as were those not taking opioids.
• Patients using immunosuppressing opioids were nearly 1.9 times as likely to get pneumonia as were those not using opioids.
• Use of opioids for a longer time period, defined as three months or more before getting pneumonia, was not associated with infection.
• Taking benzodiazepines did not affect the risk of getting pneumonia.

This was the first large epidemiological study to look at how opioid use affects the risk of getting pneumonia in a general population. It lays the foundation for research on additional questions about the safety of opioid drugs in older Americans.

"Benzodiazepines don't seem to be associated with increased risk of pneumonia," said Dr. Dublin. "But our results mean that it is crucial to look more closely at opioid prescriptions and infections."

Provided by Group Health Research Institute

Opioid use associated with increased risk of adverse events among older adults

Opioids appear to be associated with more adverse events among older adults with arthritis than other commonly used analgesics, including coxibs and non-steroidal anti-inflammatories, according to a report in the December 13/27 issue of Archives of Internal Medicine. In a second report assessing only opioid use, different types of drugs within the class were associated with different safety events among older patients with non-malignant pain.

19 dec 2010--"In the United States, one in five adults received a prescription for an analgesic in 2006, accounting for 230 million prescription purchases; however, the comparative safety of these drugs is unclear," the authors write as background information in one of the articles. "Although the cardiovascular safety of nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) and selective cyclooxygenase-2 inhibitors (coxibs) has been called into question, there is little comparable information about the third major analgesic group, opioids."

In the first report, Daniel H. Solomon, M.D., M.P.H., and colleagues at Brigham and Women's Hospital, Boston, examined the comparative safety of nsNSAIDs, coxibs and opioids among 12,840 Medicare beneficiaries who received at least one of these analgesics between 1999 and 2005. Using data from a large health care utilization (claims) database, the authors evaluated the occurrence of cardiovascular events (heart attacks, stroke and heart failure, among others), gastrointestinal events (GI tract bleeding and bowel obstruction), acute kidney injuries, toxic effects on the liver, as well as falls and fractures.

Opioid users experienced higher rates for most types of serious adverse events than patients taking coxibs or nsNSAIDs, and nsNSAID users experienced the lowest risks. For example, fractures occurred among 101 per 1,000 opioid users per year, compared with 19 per 1,000 per year among coxib users.

Coxibs and opioids appear to be associated with greater cardiac risks than nsNSAIDs, but use of opioids and not coxibs was associated with a greater risk of hospitalization or death than use of nsNSAIDs. Conversely, the risk of gastrointestinal tract bleeding was reduced among those taking coxibs (12 per 1,000 per year, compared with 21 per 1,000 per year among those taking nsNSAIDs).

"Analgesics are used daily by millions of people; however, current data do not allow patients or physicians to determine which type of agent is safest. We compared nsNSAIDs, coxibs and opioids across a wide range of specific safety events and several composite safety events," the authors write. "Although nsNSAIDs pose certain risks, these analyses support the safety of these agents compared with other analgesics. The recent concerns raised about opioid use in non-malignant pain syndromes appear warranted on the basis of these data."

In a second article, Dr. Solomon and colleagues at Brigham and Women's Hospital studied only those Medicare beneficiaries who received opioids for non-malignant pain between 1996 and 2005. They compared the rates of adverse events after 30 and 180 days among 6,275 patients each taking one of five types of opioids: codeine, hydrocodone, oxycodone, propoxyphene and tramadol.

The risk of gastrointestinal adverse events remained similar for all the medications studied, and thirty days after beginning opioid therapy, the risk of cardiovascular events was also similar across all types. However, after 180 days, the risk of cardiovascular events was increased among those taking codeine. With hydrocodone as the reference point, risk of fracture was 79 percent lower among those taking tramadol and 46 percent lower among those taking propoxyphene. Compared with those taking hydrocodone, death from any cause was 2.4 times as likely among those taking oxycodone and twice as likely among those taking codeine.

"This study's findings do not agree with a commonly held belief that all opioids are associated with similar risk," the authors write. "The risks were not explained by the dosage being prescribed and did not vary across a range of sensitivity analyses. The risks were substantial and translated into numbers needed to treat that would be considered clinically significant. Our findings regarding cardiovascular risk were surprising and require validation in other data sets."

Proving a cause-and-effect relationship between types of opioids and adverse events requires an experimental rather than observation study design, they note, "but these results should prompt caution and further study."

In addition, a research letter, published in the same issue, found double the risk of cardiovascular events among patients followed for a median (midpoint) of 189 days after they stopped taking the analgesic drug rofecoxib during off-drug follow-up of a clinical trial. Joseph S. Ross, M.D., M.H.S., of Yale University School of Medicine, and colleagues analyzed data from a clinical trial that became available through litigation. Twenty-two cardiovascular events and 23 deaths occurred among patients who had taken rofecoxib in the trial, compared with six cardiovascular events and nine deaths among participants who took placebo.

More information: Arch Intern Med. 2010;170[22]:1968-1978, 1979-1986, 2035-2036.

Provided by JAMA and Archives Journals