The most common drugs involved in fatal overdoses listed on death certificates are prescription opioid painkillers, often obtained illicitly, investigators report.

The worsening abuse of potent opioid drugs, such as oxycodone or fentanyl, coincides with an increase in the prescribing of these drugs by doctors, who have been encouraged to treat chronic pain more effectively, Dr. Leonard J. Paulozzi and associates explain in their article in the journal Pharmacoepidemiology and Drug Safety.

However, they say the two trends are not necessarily connected, and they recommend that prevention of opioid abuse should not diminish the quality of care for patients with a legitimate need for pain relief.

The researchers, based at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, evaluated trends in drug poisoning deaths using government databases.

Between 1979 and 1990, the mortality rate for unintentional drug poisoning rose nearly 60 percent, they report, an increase of 5.3 percent per year. From 1990 to 2002, the rate increased by more than 200 percent, at an average of 18.1 percent per year.

Opioids were responsible for more deaths than cocaine or heroin by the year 2002.

Drug overdose deaths predominantly involved middle-aged men, supporting the contention that drug abuse was responsible for the increased mortality, Paulozzi’s team points out, rather than appropriate use by patients with chronic pain, who are more likely to be older women.

Further evidence comes from medical examiner reports suggesting that most victims have a history of substance abuse, and do not have a prescription for an opiate drug, the researchers add.

“Drug abuse and under-treated pain are both public health crises, but the solution to one need not undermine the other,” Dr. Scott M. Fishman writes in a related commentary.

Fishman, from the University of California, Davis, argues that the new findings should not be used as evidence that “prescription drug abuse is mostly related to prescribers and their patients, implying that limiting medically appropriate use will have any effect on reversing this disturbing trend.”

Otherwise, he fears that law enforcement rather than physicians may eventually govern the use of powerful painkillers, which could lead to ineffective treatment for “suffering patients who legitimately deserve relief.”

In a second editorial, Dr. Aaron M. Gilson and David E. Joranson maintain that recreational users and individuals with mental illness, rather than chronic pain patients, are the primary victims of death by opioid overdose.

The editorialists, both from the University of Wisconsin in Madison, say, “Reports indicate opioid analgesics are stolen from medicine cabinets, sold by patients, obtained from ‘pill mills,’ the internet, forgery, and ‘doctor-shopping’.” Robberies from pharmacies and hospitals are also common but underreported, they add.

Gilson and Joranson conclude, “The fact that large quantities of abused opioid analgesics are diverted directly from the supply chain, completely bypassing the involvement of ordinarily conscientious healthcare professionals, underscores the need to develop abuse-resistant medications.”

SOURCE: Pharmacoepidemiology and Drug Safety, online July 23, 2006.