Prescription opioid abuse: What is the real problem and how do we fix it?

M.E. Lynch; Benedikt Fischer

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Opioids are not safer than NSAIDs
Irfan A. Dhalla

Published on: 18 November 2011

Published on: (18 November 2011)
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Opioids are not safer than NSAIDs
Irfan A. Dhalla, MD, MSc, FRCPC
In their comparison of our research on opioid-related mortality1 with previous research on the safety of NSAIDs2, Lynch and Fischer imply that opioids are safer than NSAIDs.3
We have shown that the opioid-related mortality rate among public drug plan beneficiaries who are prescribed opioids for non-cancer pain is 1.86 per 1000 (95% CI 1.64 - 2.10 per 1000) within two years and 7.92 per 1000 among the small pr...
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In their comparison of our research on opioid-related mortality1 with previous research on the safety of NSAIDs2, Lynch and Fischer imply that opioids are safer than NSAIDs.3
We have shown that the opioid-related mortality rate among public drug plan beneficiaries who are prescribed opioids for non-cancer pain is 1.86 per 1000 (95% CI 1.64 - 2.10 per 1000) within two years and 7.92 per 1000 among the small proportion who were prescribed more than 200 mg of morphine or equivalent per year.4 The all-cause mortality rate among patients prescribed opioids for non-cancer pain is approximately 1% per year, roughly 5 times higher than in patients who are not prescribed opioids.
The opioid-related mortality rate of 27.2 per 1 000 0001 cited by Lynch and Fischer is a population-level statistic that includes all Ontarians in the denominator, not just those prescribed opioids. It is incorrect and misleading to contrast this with the rate of NSAID-related mortality in patients who are treated with NSAIDs.
Only a well-designed randomized trial would definitively assess the relative safety of opioids and NSAIDs. No such studies exist, and we must therefore look to observational studies for the best available evidence. In a high-quality cohort study, Solomon et al. recently showed that older adults prescribed opioids were almost twice as likely to die as patients prescribed NSAIDs.5
Based on these data as well as our own, we believe it is reasonable to conclude that, as currently used in clinical practice, opioids are more dangerous than NSAIDs. This is consistent with recommendations from the World Health Organization that acetaminophen and NSAIDs be used before opioids.6
Irfan A. Dhalla, MD, MSc, FRCPC Tara Gomes, MHSc Muhammad M. Mamdani, PharmD MA MPH David N. Juurlink, MD, PhD, FRCPC
1. Dhalla IA, Mamdani MM, Sivilotti MLA, Kopp A, Qureshi O, Juurlink DN. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Canadian Medical Association Journal 2009;181(12):891-6.
2. Tramer MR, Moore RA, Reynolds DJ, McQuay HJ. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. Pain 2000 Mar;85(1-2):169-82.
3. Lynch ME, Fischer B. Prescription opioid abuse. Can Fam Physician 2011 Nov 1;57(11):1241-2.
4. Gomes T, Juurlink DN, Dhalla IA, Mailis-Gagnon A, Paterson JM, Mamdani MM. Trends in opioid use and dosing among socio-economically disadvantaged patients. Open Medicine 2011;5.
5. Solomon DH, Rassen JA, Glynn RJ, Lee J, Levin R, Schneeweiss S. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med 2010 Dec 13;170(22):1968-76.
6. WHO's pain ladder. World Health Organization. http://www.who.int/cancer/palliative/painladder/en/. Accessed: 2011 Nov 15.
Conflict of Interest:
None declared
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Competing Interests: None declared.