Predictors of overdose following opioids prescribed for chronic pain – Turns out Opioid overdose in chronic pain patients is vanishingly rare!

But don’t report that…just report the relative risk so that no one notices

Last week yet another study hit the media titled ‘Predictors of Fatal and Non-Fatal Overdose Following Prescription of Opioids for Chronic Pain:  A Systematic Review and Meta-Analysis of Observational Studies’

The authors were trying to elucidate which factors are more likely to lead to opioid overdose in the chronic pain population and put a number on that risk.  What they actually showed is that opioid overdose is very, very rare – occurring in less than 1% of people.

I have no doubt this result was not intended, nor pleasing to them.  Amongst the authors is Dr Jason Busse, a well-known anti-opioid zealot who has been instrumental in denying chronic pain patients access to safe, effective, long-term opioid therapy.  He was involved in Canada’s Opioid Prescribing Guidelines, and he pushed very strongly that doses higher than 50MME should not be necessary, and that opioids should NEVER be prescribed at a dose of over 90MME.

This ignores basic science on how opioids are metabolised.  Simply put, people metabolise opioids differently, due to their individual biology, genetics, tolerance, intensity of pain and other factors.  There is NO place for opioid dose ceilings in chronic pain management.  Chronic pain, and opioid pain medication doses, are unique and individual for each patient.  There can be NO one size fits all.  

Dr Jason Busse has repeatedly demonstrated that he is prepared to ignore scientific fact to push his anti-opioid agenda.  Yet Dr Busse still subscribes to the view that opioids should not be prescribed for chronic pain, despite his own study showing that the risk of overdose is less than 1%.

But why let the facts get in the way of a good story?  These researchers certainly didn’t.  Their solution – just don’t report it!  Cherry-pick the data and selectively report the relative risks only to the media.

Because we know journalists don’t check, they don’t read the study.  The read the press release and regurgitate it.

This is pretty much standard in research related to chronic pain and opioids. Because ‘everybody knows’ opioids are bad, right?

It’s also worth noting that another of the co-authors is David Juurlink, MD, a well-known anti-opioid zealot and member of Physicians for Responsible Opioid Prescribing (PROP), the group that started the force-tapering crisis and the untreated pain crisis in the US, which has spread around the western world.  Despite the US being the only country that has an opioid crisis. And that the US opioid crisis is driven by illicit, not prescription, opioids.

What the study found

The review included 28 studies (23, 963,716 patients) and reported on the association of 103 factors with opioid overdose for people prescribed opioids for chronic pain.  The authors stated they found Moderate-to-High certainty evidence that there were 10 factors that ‘supported large associations with opioid overdose’.

This is a direct quote from the study, from the ‘results’ section :

“Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78–9.04), higher opioid dose (OR 2.57, 95% CI 2.08–3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57–6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35–5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30–3.41), current substance use disorder (OR 2.62, 95% CI 2.09–3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73–2.61), depression (OR 2.22, 95% CI 1.57–3.14), bipolar disorder (OR 2.07, 95% CI 1.77–2.41) or pancreatitis (OR 2.00, 95% CI 1.52–2.64), with absolute risks among patients with the predictor ranging from 2–6 per 1000 for fatal overdose and 4–12 per 1000 for nonfatal overdose.”

At the bottom, last line, you can see that the absolute risks of overdose was in the range of 2-6 PER THOUSAND for fatal overdose and 4-12 PER THOUSAND for nonfatal overdose.

Therefore, the absolute risk of opioid overdose for chronic pain patients is LESS THAN ONE PERCENT.

The authors reported their results in such a way as to obfuscate that fact, and not ONE media article mentioned that the absolute risk for overdose is tiny. 

This is a common tactic for researchers who don’t want to report what their study actually found, when the data does not agree with their predetermined anti-opioid narrative.  Relative risk can make the issue sound much worse and hide the real risk – the absolute risk – which is tiny.

But there’s more.  Let’s look again at how they reported the factors that lead to overdose.

The study authors reported the risk factors in this order:

“Moderate- to high-certainty evidence supported large relative associations with:

history of overdose (OR 5.85, 95% CI 3.78–9.04),

higher opioid dose (OR 2.57, 95% CI 2.08–3.18 per 90-mg increment),

3 or more prescribers (OR 4.68, 95% CI 3.57–6.12),

4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35–5.57),

prescription of fentanyl (OR 2.80, 95% CI 2.30–3.41),

current substance use disorder (OR 2.62, 95% CI 2.09–3.27),

any mental health diagnosis (OR 2.12, 95% CI 1.73–2.61),

depression (OR 2.22, 95% CI 1.57–3.14),

bipolar disorder (OR 2.07, 95% CI 1.77–2.41) or

pancreatitis (OR 2.00, 95% CI 1.52–2.64)”

Higher opioid dose is listed second. But look at the numbers….’higher opioid dose’ is not the second highest risk.  Its way down the list. But the authors, including Dr Jason Busse who has campaigned fiercely that opioid doses need to be under 50MME and should NEVER exceed 90MME, have placed ‘higher opioid dose’ as the second most important risk. 

How interesting!

This means that they are reporting these risks in a random order.  Obviously, anyone who doesn’t read closely would be assuming that they are reporting in descending order of risk, because that is the rational way to report this data, its what you would expect.  They clearly chose this order to artificially give the impression that ‘higher opioid dose’ was a more serious risk factor.

To my mind, this qualifies as ‘deceptive reporting’ as well.  These authors are doing their very best to demonize opioids in the face of data that shows opioids to be very safe.

This is the ACTUAL order, in descending order of risk. Now, ‘higher opioid dose’ is clearly way down the list, at number six.  More than halfway down, a very low risk factor.

history of overdose (OR 5.85, 95% CI 3.78–9.04),

4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35–5.57),

3 or more prescribers (OR 4.68, 95% CI 3.57–6.12),

prescription of fentanyl (OR 2.80, 95% CI 2.30–3.41),

current substance use disorder (OR 2.62, 95% CI 2.09–3.27),

higher opioid dose (OR 2.57, 95% CI 2.08–3.18 per 90-mg increment),

depression (OR 2.22, 95% CI 1.57–3.14),

any mental health diagnosis (OR 2.12, 95% CI 1.73–2.61),

bipolar disorder (OR 2.07, 95% CI 1.77–2.41) or

pancreatitis (OR 2.00, 95% CI 1.52–2.64),

Which flies in the face of Dr Jason Busse’s opinions.  And shows his opinions to be unfounded, not based on evidence.  This should make everyone question his credibility and motives.

They stated that these ten factors had a large influence on opioid overdose.  But the absolute risk of opioid overdose in chronic pain patients, in this very large systematic review of over 23 MILLION patients, found the overdose rate is LESS than one percent. 

On WHAT planet is less than one percent a LARGE risk?  None of these factors conferred a large risk, because the overall risk of overdose was minute.   How do they write these words, and report them, with a straight face?

The risk of opioid overdose in chronic pain patients is tiny.  Opioids are very safe. 

This is what all the high-quality studies find, but the media won’t report it.  The media won’t report it because the scientists massage the data and phrase their press releases to hide the truth.  Journalists write what the press release says, because that’s much easier than reading the actual study, and fact checking.

And people living with severe, disabling pain suffer.

Let’s look at who reported on this study.

News medical says it puts medical and scientific news in reach of people that can make a difference. The are trying to influence doctors’ treatment decisions.

Yet they did not report accurately, they falsely listed ‘high dose opioids’ as the first risk factor, implying highest risk. And worse, they implied that overdose risk is high.  Nowhere did they report the absolute risk of opioid overdose as less than one percent. 

McMaster University reported the study here.

Again, reporting the risk of opioid overdose - both fatal and nonfatal - was two to six times higher with high-dose opioids, and fentanyl prescription, implying those are the highest risk factors, which is false.  This article is almost identical to the above, clearly regurgitating the press release, without reading the study.  The article’s tone is anti-opioid, and implies that opioid overdose is common, which is the opposite of what the study found. They do NOT mention the absolute risk is less than one percent.

MD Edge bills itself as the independent news source for internal medicine specialists.

They too reported incorrectly that the highest risk factors for opioid overdose are high dose opioids and fentanyl.  They DID report that risk of opioid overdose was 1.3 per 1000 for fatal overdose and 3 per 1000 for non-fatal overdose, but this is buried in the text.   It should be a headline, to draw attention to the fact that overdose is very rare, but at least they appear to have read the study.

The point is, its painfully obvious that it doesn’t matter what the study finds, what matters is what the researchers put in their press release.  

There is no oversight in chronic pain and opioid research, and particularly in how it’s reported.  All universities have ethics policies that include accurate reporting of results, but no one checks and no one cares.  It’s the wild, wild west, and this is how most people have been brainwashed - false reporting, and cherry-picked data.   This has been going on for more than ten years, and now most people, including doctors, have deeply entrenched biases based on lies.

Getting people, especially doctors, to read the truth, is an uphill battle.  Who wants to accept that they’ve been had? Lied to, deceived, and worse that they’ve made treatment decisions based on bad information, and have caused serious patient harms?  All because they didn’t bother reading the source material and trusted the headlines.

Meanwhile chronic pain patients who live with progressive, painful, incurable disease are being force tapered off their safe and effective opioid therapy.  For what reason?  Certainly not overdose risk!

And not addiction risk, as this previous recent study showed.

So why is this still happening? 

Because no one is advocating for us.  Our peak bodies are ignoring the opioid tapering and repeating the bad science. 

There are a few doctors who still prescribe, swimming against the tide, because their years of clinical experience tell them that opioids are safe and effective for people living with severe pain from progressive diseases.  But these doctors are the minority, under constant pressure to taper.

And people living with severe, disabling pain continue to suffer.

Read the science.  Learn more about our work at Pain Patient Advocacy Australia.  Please sign our petition to stop the forced tapering of people off their safe and effective long-term opioid therapy.