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Hydrocodone with Acetaminophen Tablets on a Prescription Form

Opioids and Patient Safety

According to the CDC, overdose deaths involving prescription opioids have quadrupled since 1999, and so have sales of these prescription drugs.3 From 1999 to 2015, more than 183,000 people have died in the U.S. from overdoses related to prescription.

Prescription opioids used to treat moderate to severe pain include oxycodone/OxyContin, hydrocodone (Vicodin), morphine, and methadone. Fentanyl is a synthetic opioid pain reliever, more powerful than other opioids used for severe pain, typically in advanced cancer. Heroin is an illegal opioid.

An estimated 2.1 million people in the U.S. struggle with an opioid use disorder.  Rates of opioid addiction and overdose deaths are continuing to rise. Since 2010, the number of opioid overdose deaths has doubled from more than 21,000 to more than 42,000 in 2016.

Despite current efforts, the U.S. opioid overdose epidemic continues to worsen according to a 2018 CDC report opens in a new tab that found emergency department visits for suspected opioid overdoses increased 30 percent from July 2016 through September 2017.

Naloxone is a drug that is used to temporarily reverse the effects of an opioid overdose. Although there is evidence on the effectiveness of naloxone in reducing opioid overdose deaths, awareness of the drug’s benefits and its possession and use among patients, prescribers, community bystanders, and even first responders in some areas remains limited.

The U.S. Surgeon General released a Public Health Advisory opens in a new tab on April 5, 2018, Naloxone and Opioid Overdose, to expand the awareness and availability of naloxone. The Advisory recommends that more individuals, including family, friends, and those who are personally at risk for an opioid overdose, also keep this lifesaving drug on hand.

For more information on community and outpatient opioid misuse, visit our section on risks in community and outpatient setting.

Even one opioid prescription can trigger long term dependence/use and addiction. More than 259 million prescriptions were written for opioids in 2012, according to CDC, which is more than enough to give every American adult their own bottle of pills. In 2015, more than 2 million Americans abused or were dependent on opioids.

The risk of chronic opioid use was found to increase with each additional day of opioid medication use starting with the third day, with sharpest increase in chronic use after the fifth and thirty-first day, a second prescription or refill, and an initial 10 or 30 day supply (CDC 2017).

Opioids create artificial “endorphins” in the brain and nervous system to produce pleasurable effects and relieve pain. Within the first few days on opioids, the body gradually stops making its own endorphins naturally. Often when opioids are stopped abruptly without tapering people can suffer withdrawal symptoms, including worsening pain, nausea, anxiety, depression, restlessness, suicidal thoughts and other debilitating effects. Staying on the opioids, even after the pain is gone, is the only way to feel good and avoid these symptoms.

Opioid-related hospitalizations and emergency department (ED) visits reflect this rise in opioid use. During a ten year period (2009 to 2014) opioid-related inpatient stays increased by 64 percent and opioid-related ED visits increased 99 percent (AHRQ 2017 PDF opens in a new tab) Opioids were also responsible for half of the more than 1.2 million emergency department visits in the U.S. involving the nonmedical use of pharmaceuticals, the top two being hydrocodone and oxycodone. The trend for opioid overdose visits to the ED has continued at an alarming rate with a 30% increase in ED visits – July 2016 to Sept 2017 (CDC 2018 opens in a new tab).

Premier research found that opioids were used in more than half of hospital admissions of non-surgical patients at 286 U.S. hospitals opens in a new tab. Among pediatric inpatients, Premier research identified two specific opioids (fentanyl and morphine) were found to be among the top 10 most administered medications. opens in a new tab

Adverse effects from opioids can occur in patients in any setting receiving any opioid drug, including fentanyl, hydrocodone, oxycodone, hydromorphone, morphine and methadone. Adverse effects include nausea, vomiting, constipation, falls, hypotension, hallucinations, delirium, aspiration pneumonia, respiratory depression and even death.

In the inpatient setting, opioids are among the drugs most frequently associated with adverse reactions. In one large study, opioids were responsible for 16 percent of drug-related adverse effects. A study of post-surgical patients found that almost 14 percent of those who received opioids experienced an adverse event. The study also found that the risk of death while hospitalized was more than three times higher among the patients who experienced an adverse effect associated with opioids compared with patients who did not. (For more information, visit our section on hospitals-inpatients safer opioid use for additional information.)

In the community or outpatient setting opioid misuse has become a significant health threat in the US. Although all age groups are involved, the Medicare population has among the fastest growing rates of opioid use disorders (physical/psychological dependence or addiction), currently at more than 6 of every 1,000 beneficiaries. For Medicaid beneficiaries, the prevalence of diagnosed opioid use disorder is even higher, at 8.7 per 1,000, a figure estimated to be over 10 times higher than in populations who receive coverage under private insurance companies.

2017 study in JAMA-Surgery found that 6 percent of 36,177 patients without opioid use in past year who were prescribed opioids for surgical procedures, including minor outpatient procedures, were still on opioids 3 months later, long after most should have recovered. There was no difference in long term opioid use between those who had minor outpatient vs major surgical procedures. Extrapolated to just the 50 million outpatient procedures each year, this represents up to 3 million that may become newly dependent on opioids.

For more information, visit our section on risks in community and outpatient setting.

The epidemic of addiction to opioids is the major driver of drug diversion and can occur at any point along the supply chain. Drug diversion in healthcare facilities (employee stealing for their own use) results in care delivered by impaired provider, denial of essential pain therapy, and outbreaks from hepatitis C virus or bacterial pathogens when tampering with injectable opioids involving hundreds of patients, according to the CDC.  For more information visit our section on Drug Diversion.

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