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To examine trends in opioid poisonings and adverse effects in Washington (WA) State and nationally.We calculated rates of opioid poisonings and adverse effects and examined opioid prescriptions in the WA workers' compensation system, 2004–2010. Using Health Care Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS) data, we also calculated national rates of opioid poisonings and adverse effects, 1993–2010.We identified 96 opioid poisonings and 312 opioid-related adverse effects in WA, 2004–2010. The rates did not change substantially over these years. Most poisonings and adverse effects occurred in cases without chronic opioid use and with prescribed doses <120 mg/day morphine-equivalent dose. Nationally, the rates of opioid poisonings and adverse effects increased significantly from 1993 to 2010.Many poisonings and adverse effects occurred in patients without high dose or long-term opioid therapy, suggesting that opioid dosing and duration guidelines may not be sufficient to reduce morbidity related to prescription opioid use. Am. J. Ind. Med. 56:1452–1462, 2013. © 2013 Wiley Periodicals, Inc.