hammer and spanner mismatch

The opioids and addiction mismatch

Will an increasing pressure on prescribers curb the rising opioid overdose rates?

With only 0.5% of patients prescribed opioids reportedly developing addictions, there must be something else going on that’s making people overdose. A mismatch. Research on this topic is messy and patchy–– simply put, the large correlational research and incidence studies of addiction do not match up. In a recent commentary, we outline how prescription opioids might indirectly influence the rising overdose and addiction rates.

Mismatch: Why Correlation and Incidence Might Not Match Up

First, diversion gets medically prescribed opioids (MPOs) to those who are not prescribed the medication. Diverted MPOs can be sold, gifted (mostly to family members or friends), stolen, or sometimes obtained through “doctor shopping”, where patients get the same prescription from multiple physicians. But we don’t know how much diversion is due to sold, gifted or stolen medicines. How much do the different diversion types contribute to addiction and overdose? And for that matter, how much is diversion occurring, and to what extent is it contributing to national opioid crises?

We need to start accepting that biological factors are a part of this picture

Second, because overdose is often preceded by addiction, many researchers have focused on the persons who develop an addiction when prescribed opioids. However, if addiction doesn’t come before overdose, some high-risk patients go unstudied, and thus unreported. This has been shown in some states, such as West Virginia, where prescription opioids contributed to 93% of overdose deaths and very few of the deceased had iatrogenic addiction. So, some people might be at risk of sudden overdose but are missed in research studies that focus on medical diagnoses of addiction. This gap in the research is likely due the difficulty of studying overdose risk without the presence of addiction.

Polydrug use and overdose

Third, polydrug use may lead to overdose in people who use prescription opioids but do not specifically have addiction to their MPO. Here benzodiazepines are a big issue. It is important to note that many studies of addiction to MPOs do account for polydrug use by incorporating urine drug screens; however, positive results are often lumped together with other “aberrant” behaviours such as failed pill counts or requesting opioids from multiple doctors. Ultimately,  we can’t tell how much polydrug use is really leading to addiction or overdose in this context.

Finally, it is possible that incidence studies to date could be misrepresenting the true risk of addiction to MPOs. Studies of OUD incidence in pain care use definitions of addiction that range from very broad to highly specific, mixing up terms like “dependence”, “abuse”, “misuse”, or “problematic use”. This could make it so our guesses about the risk of addiction to MPOs are muddled, leading to skewed results.

We need to understand better if reduced opioid prescriptions can reduce the opioid crisis. Then we can make the change happen.

To read the whole commentary, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:

Gorfinkel, L., Wood, E., Klimas, J. (In Press) Prescription opioids, opioid use disorder, and Overdose Crisis: Current Dilemmas and Remaining Questions. (Published ahead of Print, June 4th) Canadian Journal on Addiction

I thank Lauren Gorfinkel for feedback on this post.

If you enjoyed reading this post, you may also like my poem about pain. See link below: