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A systematic compilation of reports published on opioid-related problems

Matthew Butts, MD, Aminah Jatoi, MD


Objectives: This study examined the published literature on case reports of opioid-related problems to create a compendium that might lead to greater awareness and fewer such events.
Methods: PubMed, Ovid, and the Cumulative Index to Nursing and Allied Health Literature were searched for case reports. A problem was defined as a healthcare provider’s or patient’s administration of an opioid in an unintended manner resulting in harm.
Results: From more than 2,200+ unique articles, 104 met the inclusion criteria. Fentanyl was most implicated. Problems included pump programming errors, patients’ chewing transdermal patches, and pediatric overdosing with an oral droplet dispenser. Of 105 articles, 19 focused on patients with cancer and 86 on patients without cancer.
Conclusions: This compendium of opioid-related problems might generate further discussion about how best to reduce their number and morbidity.


opioids, mistakes, quality, cancer

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American Cancer Society: Available at Accessed April 22, 2010.

Joranson DE, Gilson AM, Dahl JL, et al.: Pain management, controlled substances, and state medical board policy: A decade of change. J Pain Symptom Manage. 2002; 23: 138-147.

World Health Organization: Cancer Pain Relief. Geneva, Switzerland: WHO, 1986.

Cleeland CS, Gonin R, Hatfield AK, et al.: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994; 330: 592-596.

Zhukovsky DS, Gorowski E, Hausdorff J, et al.: Unmet analgesic needs in cancer patients. J Pain Symptom Manage. 1995; 10(2): 113-119.

Hill CS Jr: The negative effect of regulatory agencies on adequate pain control. Prim Care Cancer. 1989; 11: 45-53.

American Medical Association House of Delegates: Protection for Physicians Who Prescribe Pain Medication. Chicago, IL: AMA, 1997.

Gilson AM, Joranson DE: Controlled substances and pain management: Changing knowledge and attitudes of medical regulators. J Pain Symptom Manage. 2001; 21(3): 227-237.

Sayers M, Marando R, Fisher S, et al.: No need for pain. J Healthc Qual. 2000; 22: 10-15.

Phillips D: JCAHO pain management standards are unveiled. JAMA. 2000: 284: 428-429.

Davis MP, Lasheen W, Garnier P: Practical guide to opioids and their complications in managing cancer pain. What oncologists need to know. Oncology. 2007; 21: 1229-1238.

Repenshek M: The principle of double effect and pain medication. Health Care Ethics USA. 2004; 12: E2.

Bresicia FJ: Philosophical oncology: Calling on the principle of double effect. J Natl Compr Canc Netw. 2003; 1: 429-434.

Dy SM, Shore AD, Hicks RW, et al.: Medication errors with opioids; results from a national reporting system. J Opioid Manag. 2007; 3: 189-194.

Paulozzi LJ, Budnitz DS, Yongli X: Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006; 15: 618-627.

Weiss SC, Emanuel LL, Fairclough DL, et al.: Understanding the experience of pain in terminally ill patients. Lancet. 2001; 357: 1311-1315.

Available at Accessed January 29, 2010.

Kaldjian LC, Jones EW, Wu BJ, et al.: Reporting medical errors to improve patient safety: A survey of physicians in teaching hospitals. Arch Intern Med. 2008; 168: 40-46.

Jarlbaeck L, Anderson M, Kgragstrup J, et al.: Cancer patients’ share in a population’s use of opioids. J Pain Symptom Manage. 2004; 27: 36-43.

Williams RE, Sampson TJ, Kalilani L, et al.: Epidemiology of opioid claims in the United States. J Opioid Manag. 2008; 4: 145-152.

Joranson DE, Cleeland CS, Weissman DE, et al.: Opioids for chronic cancer and non-cancer pain: A survey of state medical board members. J Med Licen Discipl. 1992; 79: 15-49.



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