Opioid analgesic dose and the risk of misuse, overdose, and death: A narrative review

Abstract

The reviewed studies show an increasing risk of serious adverse health outcomes-including misuse, overdose, and death-associated with increasing opioid analgesic dose. Further research is needed to characterize the relationship between opioid analgesic dose and the risk of addiction and abuse. This analysis could inform policy actions for regulators and clinical decision making for providers.

Commentary on “Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base”

“…This variability suggests that uniform prescribing limits may not be the most effective path forward; prescribing according to a single threshold may lead to inadequate pain control for some patients and excess supply for others. Prescribing thresholds may provide a false sense of safety when prescribing below that threshold . Finding the right balance between adequately treating pain and minimizing the risk for adverse outcomes in patients and others in the community will require studies to consider both patient‐level and community‐level outcomes and, as Ranapurwala and colleagues note, analytic methods to account for concurrent interventions…”

“…Prescribing thresholds may provide a false sense of safety when prescribing below that threshold. 12 Finding the right balance between adequately treating pain and minimizing the risk for adverse outcomes in patients and others in the community will require studies to consider both patient-level and community-level outcomes and, as Ranapurwala and colleagues note, analytic methods to account for concurrent interventions. 13 We would like to add a note of caution to the authors' recommendation to increase the use of "big data," such as administrative claims and electronic health record (EHR) data, in studying opioid safety.…”

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

“…Our review is the first to synthesize factors associated with high-dose opioids in primary care, so comparison with existing systematic reviews is not possible. Others have conducted a narrative review on the association between opioid dose and the risk of misuse, abuse, addiction, overdose, and death which concluded that increasing opioid dose is associated with an increased risk of serious harm [35]. Quinlan and colleagues conducted a review on the risk factors for opioid dependence following surgery and proposed strategies to mitigate dependence including the avoidance of repeat opioid prescriptions postoperatively [36].…”

Anticipating the effects of restricting high‐dose preparations of strong opioids in Australia: A population‐based analysis to inform the current policy debate

“…Opioid dose is strongly linked to the risk of serious adverse health outcomes including misuse, overdose, and death . Compared with patients prescribed less than 20 oral morphine equivalents (OMEs) daily, those with dosage of over 100 OME were shown to have three to four times increased odds of opioid overdose, resulting in worldwide guideline recommendations of treatment re‐evaluation when opioid dosage reaches this threshold .…”

“…[1][2][3] Opioid dose is strongly linked to the risk of serious adverse health outcomes including misuse, overdose, and death. 7,8 Compared with patients prescribed less than 20 oral morphine equivalents (OMEs) daily, those with dosage of over 100 OME were shown to have three to four times increased odds of opioid overdose, [9][10][11][12] resulting in worldwide guideline recommendations of treatment re-evaluation when opioid dosage reaches this threshold. [13][14][15] Recently, opioids in high dose units (DUs; when taken "as directed" lead to >90 OMEs per day) have been alleged to be a major contributor to opioid overdose, particularly in vulnerable populations, such as the elderly who are more susceptible to the adverse effects of opioids.…”