Opioid tolerance and clinically recognized opioid poisoning among patients prescribed extended‐release long‐acting opioids

Abstract

Over one-third of patients initiating ≥90 MME ER/LA opioids did not have evidence of opioid tolerance. The 7 days following high dose ER/LA initiation may represent a high-risk period for clinically diagnosed opioid poisoning in patients who do not have prior opioid tolerance.

The double opioid crisis: A call for balance

“…Between 2011 and 2013, the initiation of opioid therapy in more than 182 000 long‐stay nursing home residents was largely aligned with the CDC prescribing guidelines, with only 2% of patients receiving long‐acting opioids at the start of therapy . Young et al studied the recommendation to prescribe the lowest effective dosage when initiating opioid therapy, while avoiding an increase in dosages of extended release and long‐acting (ER/LA) opioids to 90 morphine milligram equivalents (MME) or more per day, in combination with the label recommendation to establish opioid tolerance before initiation of higher dose ER/LA opioids . A large database covering over 147 million inhabitants in the United States with employer‐based insurance was used to identify adult patients initiating ER/LA opioids greater than or equal to 90MME.…”

“…Aside from the level of evidence, it is useful to know to what extent these guidelines are followed in practice. In the current issue of Pharmacoepidemiology and Drug Safety , two papers have assessed compliance with CDC recommendations . Hunnicutt et al have studied opioid prescribing in nursing homes in the United States in light of the recommendations to use immediate‐release opioids when starting treatment .…”

“…A large database covering over 147 million inhabitants in the United States with employer‐based insurance was used to identify adult patients initiating ER/LA opioids greater than or equal to 90MME. The results showed that 38% of the 372 038 initiators did not have evidence that opioid tolerance was established prior to initiation of greater than or equal to 90 MME of ER/LA opioids, which is not in line with label recommendations . It is unclear whether prior use of opioids paid in cash—and therefore unobserved in the database—may have contributed to the lack of evidence on established opioid tolerance.…”

“…Young et al also found that nontolerant patients had a 37% increased risk of diagnosis with opioid poisoning after initiation. This increased risk was limited to the first 7 days after initiation …”

“…In the current issue of Pharmacoepidemiology and Drug Safety, two papers have assessed compliance with CDC recommendations. 12,13 Hunnicutt et al have studied opioid prescribing in nursing homes in the United States in light of the recommendations to use immediate-release opioids when starting treatment. 12 Between 2011 and 2013, the initiation of opioid therapy in more than 182 000 long-stay nursing home residents was largely aligned with the CDC prescribing guidelines, with only 2% of patients receiving long-acting opioids at the start of therapy.…”