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Stanford Medicine

Addiction, Health Policy

Do opium and opioids increase mortality risk?

Overdose from prescription opioids (e.g., Oxycodone or Hydrocodone) has become one of the most common causes of accidental death in the United States. Two new articles in BMJ suggest that overdose is not the only risk about which patients, prescribers and policy makers should be concerned.

Khademi and colleagues conducted a prospective study of a cohort of 50,045 Iranians. They followed up over 99 percent of the sample and then assessed the impact of opium use on mortality. After statistically adjusting for cigarette smoking, education, age and other factors, the research team reported that opium use nearly doubled the risk of death. The number of diseases with increased incidence among opium users was large, and included tuberculosis, cancer and COPD. The results held even when the researchers excluded from analysis individuals who started using opium in response to the onset of a chronic illness.

These results do not necessarily generalize to prescription painkillers such as Oxycontin. Unlike opium, which comes directly from the poppy flower, modern, synthetic opioids are free of impurities and are never smoked. Further, opium use in Iran may be a marker for other risk factors (e.g., poor self-care habits or social isolation) for which the epidemiological study could not fully adjust.

That said, in an accompanying commentary in BMJ, Dhalla notes that preliminarystudies have found indications of higher death rates in patients who take opioid medications (versus, for example, NSAIDs). The increased death rates are not simply attributable to accidental overdoses. None of these studies of prescription opioids is definitive, but they certainly justify a larger replication research effort along the lines of the Iranian study of opium users.

The worrisome fact about prescription opioids is that their use has grown (.pdf) extraordinarily rapidly in a very short period in the United States, to over 200 million prescriptions in 2010 alone. As a result, any adverse impacts of opioids that take a few years to accrue may hit the population in a tidal wave before there is time to understand and prevent the damage.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Photo by Ingrid Taylar

4 Responses to “ Do opium and opioids increase mortality risk? ”

  1. Elliot Krane Says:

    “Dhalla notes that preliminary studies have found indications of higher death rates in patients who take opioid medications (versus, for example, NSAIDs).” Like, for example, patients with advanced cancer who take opioids rather than NSAIDs. They have a higher death rate than patients with arthritis. I’m shocked to find gambling going on around here!

    The problem with this, and Iranian study of opium (OPIUM!!), and a few other studies that are being used to beat a drum against the use of opioids, is that the underlying pain condition that is the raison d’ĂȘtre for the use of the opioids cannot be well controlled for.

    Opioid prescriptions are indeed rapidly rising in number, partly due to the success of the pain management specialty in convincing MDs to use these effective agents rather than leaving pain untreated (good), and partly due to marketing by Big Pharma (bad). And, consequently, opioid related deaths are on the rise as well, just as NSAID related deaths would increase if more NSAIDs were used (and by the way, acc. to the CDC there are >17,000 NSAID deaths in the US annually, more than opioid related deaths). But over the past 2 decades, the risk of opioid related deaths per prescribed patient has remained steady at 0.04%.

    Let’s not demonize a class of drugs and turn back the clock to when pain was untreated and inadequately treated. Rather let’s look at why and how patients are being harmed, and address safety measures.

  2. Keith Humphreys Says:

    Dr. Krane wrote: Like, for example, patients with advanced cancer who take opioids rather than NSAIDs. They have a higher death rate than patients with arthritis.

    Dr. Krane: I am afraid this is not correct. The study mentioned by Dhalla compares patients with osteoarthritis who were taking opioids or NSAIDs. It is not a comparison of opioids for cancer and NSAIDS for arthritis.

    More generally, having worked in hospice for many years and overseen a significant expansion of opioid substitution therapy in the national VA system, I see these medications as valuable. But I do not agree with you that being concerned about the potential side-effects of a medication for which one has advocated is “demonization”. To me it is humility, caution and concern about the well-being of patients.

  3. Ray Says:

    “The problem with this, and Iranian study of opium (OPIUM!!)”

    Opium is actually less hazardous than synthetic opiods and has significantly fewer side effects. The only problem with it is it is much harder to dosage than prescription meds.

  4. Carl Says:

    A bit confusing. A study of Persian addict mortality, primarily raw opium and dross, (plus a little heroin), both smoked and eaten. “Other risk factors” might include the combined negatives inherent to legal persecution and black market culture and economics (like poverty). Opium has been illegal there since 1979. And your claim that big pharmas vile thebaine derivatives and toxic petroleum derivatives are “never smoked” is quite untrue. North Americans commonly smoke and inject these drugs, even fentanyl and suboxone in gel form. And your assertion of a possible title wave to come based on this study of black market opium, dross and heroin users? I’m yawning. Looks like another hit piece on opium to me. All drugs increase mortality rates. All drugs are poison. Again: gambling here? I’m shocked.

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