Written by Clay Smith
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Patient preference for a specific analgesic should raise concern that the individual is at greater risk for overdose.
Why does this matter?
Opiate abuse is epidemic. The ED is a likely contributor. There are many ways way to determine which patients are at greater risk of abusing opiates, such as current high-dose opiate use, multiple prescriptions on a state controlled substance database, multiple ED visits for pain complaints, known prior overdose, current illicit substance abuse, evidence of IV drug abuse on exam, or open admission of opiate misuse. This study covers another important one.
I want the Dilalala, doc
This was an ED survey of patients to determine whether a patient’s preference for a specific pain medication was associated with lifetime risk of overdose. Specifically, the survey asked about opiate misuse behaviors, analgesic preferences, if they ever had a history of overdose, and other items. Out of the 2233 responses, 532 reported prior overdose. They found that having any specific analgesic preference was associated with a 48% increased odds of lifetime overdose. This was particularly marked in those with a preference for hydromorphone or morphine. Of course, this study was limited by recall bias and the fact that many patients may not answer questions about opiate abuse honestly. Remarkably, some did. What I take home is that when patients make specific requests for an analgesic by name, this should heighten concern about opiate misuse in such patients. Such patients may be at greater risk of overdose when considering outpatient prescription of opiates.
Source
Patient Preference for Pain Medication in the Emergency Department Is Associated with Non-fatal Overdose History. West J Emerg Med. 2018 Jul;19(4):722-730. doi: 10.5811/westjem.2018.4.37019. Epub 2018 Jun 11.
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Reviewed by Thomas Davis
While I don’t disagree with this data, it should be used judiciously. The "other" group of patients who request specific medications are the ones who know their condition well, have tried various treatments and have a good sense of what works best. We need to continue to attend to patient safety while not contributing to their stigmatization. I’ve had a number of patients with recurring pain issues who have significantly better responses to specific opioids (ie a tiny dose of morphine being more effective with fewer adverse effects than an ostensibly equianalgesic dose of codeine), but who sometimes get labeled as drug-seeking/misusing as a result of these studies.
This is a really important point. Thanks for bringing some balance to this.