The Nov. 17, 2010, New England Journal of Medicine includes a helpful summary on the current state of opioid prescribing in the U.S. For any physician colleague who regularly prescribes significant amounts of opioids, I strongly recommend a review of the issue. Why?
Admissions to chemical dependency treatment programs increased 400 percent between 1998 and 2008, with prescription painkillers the second most common drug of choice. Unintentional drug overdose deaths are now epidemic in our country, and the second-leading cause of accidental death.
Our anecdotal experience at the Clarian chemical dependency treatment program mirrors the Centers for Disease Control and Prevention (CDC) data, indicating oxycodone and hydrocodone are the most commonly abused drugs in recent years.
These alarming data parallel an increase in the medical use of opioids. In some 2006 CDC data, opioids were involved in 93 percent of overdose deaths, with methadone the most common cause. Methadone use has increased steeply for several reasons, including low cost and the idea that it is more difficult to abuse. This may be true for some patients.
However, in other patients it is more dangerous. The half-life varies from 8-59 hours – quite a spread.
Methadone should be used with great caution if there is concurrent use of diuretics, obstructive sleep apnea, LVH,QT prolongation, hepatic or renal insufficiency. And transitioning to methadone can be potentially hazardous because of its incomplete cross-tolerance to other opiates. (Have you done an ECG on your methadone patients?)
Appropriately, the FDA has concerns about the growing usage, and the agency is revising its Risk Evaluation and Mitigation Strategy with some advisors urging that specific training in appropriate use of opioids be made mandatory for all physicians who prescribe them.
Perhaps it is time for all of us to re-examine our individual habits and procedures. I certainly will.