Wednesday, July 3, 2013

Rx-Analgesic Overdoses Hitting Women Harder

CDCAccording to just-released data from the U.S. Centers for Disease Control and Prevention (CDC), men are still more likely to die of prescription opioid analgesic overdoses, but the gap between men and women is rapidly closing. Deaths from Rx-opioid overdoses are hitting women harder than ever, and have risen more sharply than among men. Since 1999 the percentage increase in deaths was more than 400% among women compared with 265% in men.

Writing in the July 2013 edition of CDC VitalSigns [here] and Morbidity & Mortality Weekly Report [MMWR, 2013(Jul 2);62, early release PDF here], government authorities note that nearly 48,000 women died of Rx-opioid overdoses between 1999 and 2010. Each day, about 18 women die of an Rx-opioid overdose in the U.S. — more than 6,600 deaths in 2010 alone (compared with about 10,000 in men that year). And, for every woman who dies of such overdose, 30 go to the emergency department due to analgesic misuse or abuse.

In sum, the reports notes that prescription opioid analgesic overdoses are an under-recognized and growing problem for women, and this relates closely to increased prescribing of these drugs during the past decade. Here are some additional facts from the CDC:

  • Women between the ages of 25 and 54 are more likely than other age groups to go to the emergency department due to Rx-opioid misuse or abuse.

  • Women ages 45 to 54 have the highest risk of dying from Rx-opioid overdose, whether unintentional or suicide.

  • Prescription opioids are involved in 1 in 10 suicides among women.

  • Non-Hispanic white and American Indian or Alaska Native women have the highest risk of dying from Rx-opioid overdose.

  • Women may become dependent on Rx-opioids more quickly than men.

  • Women may be more likely than men to engage in “doctor shopping” (obtaining medications from multiple prescribers).

  • Abuse of Rx-opioids by pregnant women can put their infants at risk, and cases of neonatal abstinence syndrome (NAS) grew by almost 300% in the U.S. between 2000 and 2009.

The CDC recommends that, when prescribing opioid analgesics, healthcare providers should recognize that women are at significant risk of overdose from those medications. Practitioners should follow guidelines for responsible prescribing, including screening and monitoring women for substance abuse and mental health problems. They also should use prescription drug monitoring programs (PDMPs) to identify patients who may be improperly obtaining or using Rx-opioids and other drugs. Additional guidance for prescribers from the CDC includes:

  1. Consider various pain treatment options, including ones that do not involve prescription drugs.

  2. Discuss with patients the risks and benefits of taking prescription opioids, especially during pregnancy and/or when these drugs are taken for chronic conditions.

  3. Prescribe only the quantity needed based on an appropriate pain diagnosis.

  4. Use patient-provider agreements combined with urine drug tests for people taking Rx-opioids long term.

  5. Teach patients how to safely use, store, and dispose of all medications.

  6. Avoid combinations of Rx-opioids and benzodiazepines unless there is a specific medical indication.

The CDC adds that the U.S. government is actively tracking prescription drug overdose trends to better understand the “epidemic.” Healthcare providers and the public are being educated about prescription drug misuse, abuse, suicide, and overdose, and the special risks for women. Programs and policies are focusing on preventing and treating prescription-drug abuse and overdose, while making sure patients have access to safe, effective pain treatment.

COMMENTARY:
As they customarily do, the CDC uses the more pejorative terms, “prescription painkillers” and “narcotics” in the VitalSigns report for consumers (and the news media), but the more appropriate phrase “opioid pain relievers, or OPR” is used in the MMWR document for professionals. We have protested this form of language bias that sways public attitudes in the past.

There are important limitations in the collection and accurate interpretation of data in reports such as these, which the CDC does concede. For one thing, vital statistics data may skew rates of specific drug involvement in deaths because the type of drug is not specified on many death certificates. For emergency department visits, all drugs involved may not be identified and data on motivation for drug use (eg, misuse, abuse, suicide attempt) are often incomplete. Finally, distinguishing between drugs taken for nonmedical (eg, recreational) versus medical reasons is not always possible, especially when multiple drugs are involved.

Still, the overall trends in CDC reports can be instructive if viewed objectively, without bias — and these reports certainly raise important concerns. Unfortunately, the data and tone of the reports appear to depict a universally harmful portrait of opioid analgesics and they also might be perceived as denigrating women.

The CDC VitalSigns report broadly notes that women are more likely to have chronic pain, to be prescribed prescription opioid analgesics, to be given higher doses, and to use them for longer periods of time than men. Also in women, the report states that 7 of 10 prescription-drug-related deaths include an Rx-opioid.

However, the report further observes that other prescription drugs play important roles in overdoses among women as well. Women are more likely than men to die of overdoses involving medications like antidepressants and benzodiazepines prescribed for mental health conditions. And, these drugs are especially dangerous when combined with opioid analgesics and/or alcohol.

Neither report indicates the prevalence of chronic pain in women who experienced drug-related overdoses or deaths, and whether they were being adequately treated for their pain conditions. There also is an important need to clearly distinguish between persons who were abusing the drugs in some fashion compared with those who were misusing them for medical purposes; for example, taking more drug or more often than prescribed to relieve undertreated pain.

Along those lines, there is no data in the reports on the specific types of opioids or other drugs, their doses, or their effectiveness in managing pain. In short, there still seem to be unresolved questions about whether the problems are stemming more from too much prescribing of opioids or too little effective pain control in women via pharmacotherapy or other modalities.

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