Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Can Med Assoc J 2009; 181:881–2
Opioid use has increased in Canada as have reports of opioid abuse and opioid-related mortality. This retrospective study examined the potential association between increased opioid prescribing in Canada with opioid-related mortality.
Data from IMS Health Canada were collected from 1991 to 2007 for all opioid-containing analgesics and cough suppressants prescribed on an outpatient basis. Opioid-related deaths were determined by the coroner and based on high opioid concentrations or drug combination including one opioid.
Between 1991 and 2007, the prescribing of opioid analgesics increased by 29%, from 458 to 591 prescriptions per 1,000 individuals annually, and oxycodone prescriptions increased by more than 850%. The amount of drug dispensed also increased by 24%. Of 7,099 drug or alcohol-related deaths, 3,406 involved opioids. Morphine or heroin administration was the most common cause of single opioid-related deaths (36%), compared with codeine (20%), methadone (14%), and oxycodone (11%). The majority of deaths involved one nonopioid central nervous system depressant (91.6%). The addition of long-acting oxycodone to the drug formulary was associated with a fivefold increase in oxycodone-related mortality and a 41% increase in overall opioid-related mortality. The majority of deaths were deemed unintentional.
Most patients (66.4%) had visited a physician in the month before death and of the 1,095 patients for whom individual-level prescribing data were available, 56.1% had filled a prescription for an opioid in the month before death.
This Canadian study demonstrated an association between increases in opioid prescribing and opioid-related mortality through a 10-yr period. Most deaths were associated with the use of other central nervous depressant drugs and were not ruled intentional. Importantly, visits to physicians within the month before death indicates that there may be an opportunity for interventions to prevent mortality related to opioid use in these patients.
Spinal cord stimulation for failed back surgery syndrome: Outcomes in a workers' compensation setting. PAIN 2009; 148:14–25
Failed back surgery syndrome, including chronic back and leg pain that failed to improve after spine surgery, is often treated using spinal cord stimulation (SCS). Although previous trials of SCS demonstrated favorable results compared with lumbar spine reoperation and conventional medical management, they did not always include comparisons with treatments other than reoperation or patients receiving worker's compensation, which may have worse outcomes with any pain therapy.
This prospective controlled cohort study compared pain, function, medication use, and work outcomes of patients in the Washington State Workers' Compensation Program who received SCS (n = 51) with patients who did not receive SCS (“Pain Clinic” group; n = 39) and with patients who did not receive SCS or pain clinic evaluation (“Usual Care” group; n = 68).
The average age of patients was 44 yr and most patients were men. At baseline, the SCS group had significantly longer work time loss compensation, leg pain, and claim duration compared with the other two groups. No difference was observed between groups for the primary composite endpoint of pain, function, and opioid medication use. Few (<10%) patients in any group achieved success at any follow-up. At 6 months, the SCS group showed slightly more improvement in leg pain and function, but with higher rates of daily opioid use at 6 months compared with the other two groups. However, differences were not sustained over longer periods of time.
The lack of long-term effectiveness of SCS in this population does not necessarily imply ineffectiveness in other patient populations. The issues associated with workers' compensation may have significant effect on pain therapy and patient outcomes. It is possible that subgroups in this population such as those with unilateral radicular pain, higher baseline functioning, and greater mental health status may have better results.