Abstract
The opioid epidemic continues to be a public health crisis in the US. To assess the patient factors and early time-varying prescription-related factors associated with opioid-related fatal or nonfatal overdose. This cohort study evaluated opioid-naive adult patients in Oregon using data from the Oregon Comprehensive Opioid Risk Registry, which links all payer claims data to other health data sets in the state of Oregon. The observational, population-based sample filled a first (index) opioid prescription in 2015 and was followed up until December 31, 2018. Data analyses were performed from March 1, 2020, to June 15, 2021. Overdose after the index opioid prescription. The outcome was an overdose event. The sample was followed up to identify fatal or nonfatal opioid overdoses. Patient and prescription characteristics were identified. Prescription characteristics in the first 6 months after the index prescription were modeled as cumulative, time-dependent measures that were updated monthly through the sixth month of follow-up. A time-dependent Cox proportional hazards regression model was used to assess patient and prescription characteristics that were associated with an increased risk for overdose events. The cohort comprised 236 921 patients (133 839 women [56.5%]), of whom 667 (0.3%) experienced opioid overdose. Risk of overdose was highest among individuals 75 years or older (adjusted hazard ratio [aHR], 3.22; 95% CI, 1.94-5.36) compared with those aged 35 to 44 years; men (aHR, 1.29; 95% CI, 1.10-1.51); those who were dually eligible for Medicaid and Medicare Advantage (aHR, 4.37; 95% CI, 3.09-6.18), had Medicaid (aHR, 3.77; 95% CI, 2.97-4.80), or had Medicare Advantage (aHR, 2.18; 95% CI, 1.44-3.31) compared with those with commercial insurance; those with comorbid substance use disorder (aHR, 2.74; 95% CI, 2.15-3.50), with depression (aHR, 1.26; 95% CI, 1.03-1.55), or with 1 to 2 comorbidities (aHR, 1.32; 95% CI, 1.08-1.62) or 3 or more comorbidities (aHR, 1.90; 95% CI, 1.42-2.53) compared with none. Patients were at an increased overdose risk if they filled oxycodone (aHR, 1.70; 95% CI, 1.04-2.77) or tramadol (aHR, 2.80; 95% CI, 1.34-5.84) compared with codeine; used benzodiazepines (aHR, 1.06; 95% CI, 1.01-1.11); used concurrent opioids and benzodiazepines (aHR, 2.11; 95% CI, 1.70-2.62); or filled opioids from 3 or more pharmacies over 6 months (aHR, 1.38; 95% CI, 1.09-1.75). This cohort study used a comprehensive data set to identify patient and prescription-related risk factors that were associated with opioid overdose. These findings may guide opioid counseling and monitoring, the development of clinical decision-making tools, and opioid prevention and treatment resources for individuals who are at greatest risk for opioid overdose.
Highlights
IntroductionIn the setting of the modern opioid overdose and death epidemic, use of such medications has decreased, but there were still 168.9 million opioid prescriptions in the US in 2018.1 Each prescription of an opioid to a previously opioid-naive patient creates the potential for the development of chronic opioid use and opioid use disorder.[2] For this reason, multiple entities and states have produced opioid prescribing guidelines, such as the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain in 2016 and the Oregon Acute Opioid Prescribing Guidelines in 2018.3,4 The surgical literature has declared opioid dependence to be a never-event (along with use disorder and overdose)[5] and as the most common surgical complication,[6] affecting approximately 5% to 7% of patients who started a new episode of opioid use.[7]
Opioid medications remain a mainstay of treatment of severe pain
Risk of overdose was highest among individuals 75 years or older compared with those aged 35 to 44 years; men; those who were dually eligible for Medicaid and Medicare Advantage, had Medicaid, or had Medicare Advantage compared with those with commercial insurance; those with comorbid substance use disorder, with depression, or with 1 to 2 comorbidities or 3 or more comorbidities compared with none
Summary
In the setting of the modern opioid overdose and death epidemic, use of such medications has decreased, but there were still 168.9 million opioid prescriptions in the US in 2018.1 Each prescription of an opioid to a previously opioid-naive patient creates the potential for the development of chronic opioid use and opioid use disorder.[2] For this reason, multiple entities and states have produced opioid prescribing guidelines, such as the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain in 2016 and the Oregon Acute Opioid Prescribing Guidelines in 2018.3,4 The surgical literature has declared opioid dependence to be a never-event (along with use disorder and overdose)[5] and as the most common surgical complication,[6] affecting approximately 5% to 7% of patients who started a new episode of opioid use.[7]. Previous work with the Ohio prescription drug monitoring program (PDMP) database found that different prescriber specialties had different rates of long-term use by patients[10] likely because the indications of opioid use and underlying patient factors create different risks for long-term use
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