The full content of Annals is available to subscribers

Subscribe/Learn More  >
Editorials |

Follow-up to Nonfatal Opioid Overdoses: More of the Same or an Opportunity for Change?Follow-up to Nonfatal Opioid Overdoses

Jessica Gregg, MD, PhD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 29 December 2015.

From Central City Concern, Portland, Oregon.

Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2687.

Requests for Single Reprints: Jessica Gregg, MD, PhD, Central City Concern, 1535 North Williams Avenue, Portland, OR 97232; e-mail, jessica.gregg@ccconcern.org.

Ann Intern Med. 2016;164(1):62-63. doi:10.7326/M15-2687
Text Size: A A A

In this issue, Larochelle and colleagues report that patients frequently continue to receive prescriptions for opioids after a nonfatal opioid overdose. The editorialist discusses why such problems occur and what changes are necessary to improve the care of these patients.

First Page Preview

View Large
First page PDF preview





Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Follow up to Non-Fatal Opioid Overdose
Posted on January 5, 2016
Mitchel L Galishoff, MD
Valley Medical & Surgical Clinic, PC
Conflict of Interest: None Declared
I wish to add some comments to Dr. Gregg’s editorial(1) concerning the prescribing of opioids after an overdose(2). It is indeed ironic that in an age of electronic health records and modern technology, simple communication of vital information is deficient. There was a time we called one another and assure this was passed on. It appears that this problem requires a simple solution of changing the system such that the prescribing doctor is personally contacted and a formal transfer of care achieved.
Dr. Gregg rightly mentions addiction as a driving risk factor in these overdoses. How do we change our best practices to adequately address cases wherein the patient who overdosed obtained medication that was not prescribed to them? Transfer of controlled substances by sale, theft or any means is illegal in our state. When diversion is clearly documented what are our ethical and legal obligations to inform the prescriber? What constitutes clear documentation that justifies action by a physician concerning a third party patient from whom the medication originated?
We must address other underlying causes of accidental overdose including confounding medical conditions such as drug interactions (especially with methadone), sepsis, dehydration, heart, liver, lung and renal problems (morphine, oxycodone). The metabolism of some opioids is greatly affected by acute changes in health and organ function leading to drug accumulation and adverse outcomes. Some cases are due to unpredictable acute illness and others due to recurrent problems related to comorbidities. Addressing the underlying medical condition and adjusting therapy accordingly is a logical and proper response.
Finally, it seems logical to explore avenues wherein partial agonists such as trensdermal buprenorphine can be accessed as the preferred next step when chronic opioid therapy is chosen. The major barrier is financial and coverage determinations. The same obstacle exists for naloxone products. Policy changes may be quite effective.
Pain management with opioids in patients with chronic illness can be complicated. A fragmented system of care wherein the prescriber does not possess the expertise to manage the whole patient is a deficiency that must be corrected.

1) Ann Intern Med. 2016;164(1):62-63. doi:10.7326/M15-2687

2) Marc R. Larochelle, MD, MPH; Jane M. Liebschutz, MD, MPH; Fang Zhang, PhD; Dennis Ross-Degnan, ScD; and J. Frank Wharam, MB, BCh, BAO, MPH, Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose: A Cohort Study; Ann Intern Med. 2016;164(1):1-9. doi:10.7326/M15-0038.

Opioid Related Death: An Overlooked Predisposing Factor
Posted on January 20, 2016
Richard E Moon, Jennifer V Potter
Depts of Anesthesiology and Medicine, Duke University Medical Center and Dept. of Anesthesiology, University of Virginia
Conflict of Interest: None Declared

Dr. Gregg’s editorial outlines a number of sensible strategies for approaching the recent plethora of opioid overdoses, causing hypoventilation, hypoxia and often death (1). We suggest one additional long-term strategy that deserves consideration: identification of phenotypes at high risk for opioid-induced respiratory depression (OIRD). Clinical observation has identified some of these, including conditions leading to chronic hypercapnia such as severe obstructive lung disease and obesity hypoventilation syndrome (2). Another susceptible group includes chronic opioid users who have developed tolerance to opioid analgesic effects. Animal studies and human observations have revealed that tolerance to respiratory depression develops slowly or not at all (3), thus individuals who develop tolerance to opioid analgesia and therefore tend to consume increasingly higher doses are at risk, especially during sleep (4).
Another group of high risk individuals includes those with low inherent chemosensitivity. The degree to which induced hypercapnia stimulates an increase in ventilation (hypercapnic ventilatory response, HCVR) varies among the normal population more than 80-fold. There is a strong argument and experimental evidence that low HCVR may predict those at risk for OIRD (4). Another likely high risk population may have been identified by recent observations of abnormal chemosensitivity in normal adults who were born at gestational age ≤32 weeks (5). The usual response to hypoxia is hyperventilation (hypoxic ventilatory response, HVR), however some prematurely born individuals paradoxically hypoventilate. Although opioid effects on this subpopulation have not yet been studied it is reasonable to speculate that these individuals are also at greater risk for OIRD.
Assessment of HVR and HCVR is generally limited to specially equipped labs, however the principles underlying these tests are not complicated. A simple clinical test could be developed that would allow assessment of ventilatory chemosensitivity before or during opioid therapy, in order to identify high risk patients.

Richard E Moon, MD
Professor of Anesthesiology
Professor of Medicine
Duke University Medical Center
Durham, NC      richard.moon@duke.edu

Jennifer VF Potter, MD
Fellow in Anesthesiology
University of Virginia
Charlottesville, VA  jen.potter@virginia.edu

1. Gregg J. Follow-up to nonfatal opioid overdoses: more of the same or an opportunity for change? Ann Intern Med. 2016;164(1):62-3.
2. Nelson JA, Loredo JS, Acosta JA. The obesity-hypoventilation syndrome and respiratory failure in the acute trauma patient. J Emerg Med. 2011;40(4):e67-9.
3. White JM, Irvine RJ. Mechanisms of fatal opioid overdose. Addiction. 1999;94(7):961-72.
4. Potter JV, Moon RE. Commentaries on Viewpoint: Why do some patients stop breathing after taking narcotics? Ventilatory chemosensitivity as a predictor of opioid-induced respiratory depression. J Appl Physiol (1985). 2015;119(4):420-2.
5. Bates ML, Farrell ET, Eldridge MW. Abnormal ventilatory responses in adults born prematurely. N Engl J Med. 2014;370(6):584-5.

Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Related Point of Care
Topic Collections
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.