Dead in Bed: The Dangers of
Opioids for Inpatients
Among the annual toll in
the U.S. opioid epidemic
are up to 5,000 hospital
inpatients. The drugs
they are legally
prescribed are creating
liability issues for
pharmacists as well as
By Graham Buck
Fifty years ago, the Rolling Stones sang of ‘Sister Morphine’ and the craving for the next shot of relief. The song has lost none of its relevancy — overprescribing and aggressive marketing of drugs uch as Dilaudid, Demoral, OxyContin and Ritalin during the 1990s aggravated an already-serious dependency issue.
“The idea was to provide very potent, very effective pain relief,” said Kristin
McMahon, chief claims officer, North American Specialty, Global Risk Solutions,
Liberty Mutual Insurance.
“But the drugs were aimed at elderly patients living out their last days and intended
only for a short duration — not for long-term pain relief over an extended period.”
Tackling the problem is no easy task; an estimated 42,000 drug overdose deaths
involving opioids were recorded in 2016, five times 1999’s total. While the amount
of opioids prescribed in the U.S. peaked eight years ago, it remains at high levels.
There are worrying signs that any progress in this area might be stalling. In
March, the Centers for Disease Control and Prevention (CDC) reported that
visits to emergency departments for suspected opioid overdoses rose 30 percent
between July 2016 and September 2017.
Contributing to the opioid-related mortality toll is the so-called ‘Dead in Bed’
(DiB) phenomenon, which has garnered less public attention but is well-known
within the medical community — particularly among anesthesiologists.
DiB accounts for an estimated 3,000 to 5,000 opioid-related deaths annually,
typically of patients in hospital wards rather than intensive care.
Prescribed pain killers while recovering from surgery, many inpatients suffer
respiratory failure in their sleep. Although the figure is low in relation to deaths
from infections or surgical errors, it’s still a cause for concern. Wide variations
across states in the number of cases suggest inconsistent prescribing policies
among health care providers.
HEALTH RISK FACTORS
Silvia Sacalis, vice president of clinical services for the pharmacy benefit
company Healthesystems, said the risk factors relating to prescribing opioids for
inpatients include several knowns and unknowns. Known risks include patients
suffering anxiety, depression and pain disorders, and regular users of alcohol and/
or tobacco which pre-dispose individuals to addictive behavior.
Unknown risk factors are more numerous.
“Post-surgery, the patient will often be unconscious and the system shuts down
under anesthesia,” said Sacalis.
“Certain parts of the brain don’t receive information needed for them to be
able to communicate what they’re experiencing.
“He or she might, say, have low blood pressure or an undiagnosed heart
condition. As opioids typically slow the heart rate further, this puts the patient at
risk of death.”
Other unknown risks include:
• Undiagnosed asthmatic conditions
or breathing difficulties, which worsen
• Undiagnosed liver or kidney
conditions. These organs should
metabolise and excrete the drug from
the body, but instead they allow it to
• Blockages in the intestine or
stomach. Opioids slow metabolism and
the way the stomach processes a drug,
so any blockage can prove fatal.
“All these potential factors need
to be discussed with patients and
their medical history studied before
• More inpatients are dying from
opioid use while at the hospital.
• Opiate drug prescriptions are
being monitored now more than
• Hospitals, their insurers and
pharma companies are in the
crosshairs for opioid death and
“Providers need to pay attention
to these prescription standards
of care, and risk managers
within health care organizations
are wise to monitor providers’
— Mike Midgley, vice president, healthcare risk
engineering, Swiss Re Corporate Solutions
The U.S. loses up to 5,000 inpatient lives each year to opioid-related respiratory failure.