Monday, March 5, 2007

Deaths Secondary to Opioid Poisoning; Nonagenarians & Dialysis; Pregabalin & Hot Flashes

Some of you may have seen an email circulating from the Wisconsin Pain & Policy Study Group (PPSG) about an article from last summer's Pharmacoepidemiology and Drug Safety. The email highlights an article and two commentaries regarding a causal association between increasing opioid prescriptions and increasing deaths from opioid 'poisoning*.'

The conclusion of the article is that we have entered a national epidemic of drug poisoning deaths, around the same time as increases in prescription opioid dispensing, and these may be related (inadvertently). Of the increase in unintentional deaths from poisoning, the opiate group had one of the largest % changes (+91%). In 2002, prescription opioids were implicated in more poisoning deaths (5528) than heroin (1937) or cocaine (3909). (For comparison, I have listed some CDC mortality data from 2002, so you can see the relative impact.)

Some interesting data from this study and others found that the demographics of those dying from opioid poisoning match the demographics of those dying from heroin and cocaine, mostly middle-aged males. And that most did not have a prescription for the opioid.

Well, as you can probably guess, a study like this can be intimidating to those who advocate for fair and appropriate prescribing of opioids. But as we all know:


Or 'Correlation does not imply causation.' But it does not mean we should ignore or dismiss this data. We need to read the paper and understand what it may show us. Luckily the journal that published this study included two excellent commentaries to fit along side this piece, but for those who are not keenly interested in this, I presume the abstract with the conclusion will be the only thing read which is a lazy and dangerous step. Scott Fishman, MD provides a good history of law and pain control, as well as a good summary of the problems of 'correlation equals causation.'

Joranson and Gilson provide a critical review of why this database association is difficult to translate into action, and how too much publicity of this article could cause harm:
Unwittingly, publicity about simple associations can exacerbate fears of appropriate medical use of prescription drugs among pain patients and the public, trigger more drug control, and increase fears of regulatory scrutiny among legitimate prescribers and dispensers. All of these can lead to further under-treatment of pain.
But both commentaries do address that the increase in deaths is concerning, but that we need open funding for well-designed studies that look into the complexity of drug diversion, the reasons for abuse, and not necessarily the breakdown of the prescriber-patient dyad that allows for the appropriate treatment pf pain.

For those of us in palliative care and hospice this should be an issue that you talk with your colleagues about, because as a new field we risk being defined by others, and this is not how I envision our field. Better to partner with future studies and make efforts to help address any of these problems of diversion where we are able.

*Poisoning is referred to in the article as: 'the damaging effects of ingestion, inhalation, or other exposure to solids, liquids or gases'

2) Two quickies here that I have been meaning to get off my to do list for Pallimed:

Annals of Internal Medicine had an article by Kurella looking at 80 and 90 year-old patients on hemodialysis. The number of octogenarians and nonagenarians has been increasing steadily with almost 14,000 receiving dialysis in 2003!! 1-year mortality was an impressive (impressively good I thought) 46%.

Community Oncology has a brief communication on using pregabalin (Lyrica) for vasomotor instability or 'hot flashes' for menopause, breast cancer and prostate cancer patients, and those on hormonal chemo. They gave pregabalin (open-label) to 12 patients and had some pretty impressive treatment scores with 75% of people reducing their hot flash severity by 50% or more. Although some people did experience unwanted side effects, namely sedation and altered mentation, this may be another tool to consider.

And if you have never checked out Community Oncology or the sister journal Supportive Oncology, you are missing out on some great free journals that have well-written informative accessible articles that are available online...FREE!! Go sign up. Well. Go.

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