The opioid crisis in North America

The study by Dhalla et al¹ contributes to our understanding of the effects and causes of the opioid crisis in North America. Numerous studies have documented a dramatic increase in opioid-related harms, including rising rates of opioid addiction, overdose, emergency department visits, and hospitalizations. These harms closely parallel the unprecedented increase in the prescribing of controlled-release opioids. These harms are dose-related. In one cohort study, pain patients taking 100 mg/d of morphine equivalent or more had a 9-fold increased risk of fatal or non-fatal overdose, compared with patients taking 1 to 20 mg/d.² The annual risk of overdose in the 100 mg/d group was 1.8%. Morphine at 100 mg/d is equivalent to only 30 mg of oxycodone twice daily. To my knowledge there is no other medication prescribed in primary care with such a high rate of life-threatening events.

Dhalla’s study demonstrates that there is a subgroup of physicians who are high prescribers. This suggests that educational interventions can be tailored to specific communities and individual physicians. I’ve met many high prescribers over the years; most impressed me as compassionate and caring. But they were influenced by an intense and sustained pharmaceutical marketing campaign that promoted a few simple but false messages: there is no ceiling dose for opioids; addiction is rare in pain patients; and opioids are very safe. Research, by Dhalla and by others, has shown the terrible suffering and harm that these messages have caused.