Abstract
Some selective serotonin reuptake inhibitors (SSRIs) inhibit the enzymes responsible for the metabolism of oxycodone, a potent prescription opioid. The clinical consequences of this interaction on the risk of opioid overdose have not been elucidated. To compare opioid overdose rates in patients initiating oxycodone while taking SSRIs that are potent inhibitors of the cytochrome-P450 2D6 enzyme (CYP2D6) vs SSRIs that are not. This cohort study included adults who initiated oxycodone while receiving SSRI therapy between 2000 and 2020 whose data were included in 3 US health insurance databases. Use of SSRIs that strongly inhibit CYP2D6 enzyme (fluoxetine or paroxetine) vs use of other SSRIs at the time of oxycodone initiation. Opioid overdose hospitalization or emergency department visit. Outcomes were assessed within 365 days of oxycodone initiation; in primary analyses, patients were followed up until the discontinuation of either oxycodone or their index SSRI group. Propensity score matching weights were used to adjust for confounding. Crude and weighted (adjusted) incidence rates and hazard ratios were estimated using Cox regression models, separately within each database and overall, stratifying on database. A total of 2 037 490 initiated oxycodone while taking SSRIs (1 475 114 [72.4%] women; mean [SD] age, 50.1 [15.3] years). Most (1 418 712 [69.6%]) were receiving other SSRIs at the time of oxycodone initiation. In the primary analysis, we observed 1035 overdose events (0.05% of the study cohort). The adjusted incidence rate of opioid overdose in those using inhibiting SSRIs at the time of oxycodone initiation (9.47 per 1000 person-years) was higher than in those using other SSRIs (7.66 per 1000 person-years), indicating a greater risk of overdose among patients using CYP2D6-inhibiting SSRIs (adjusted hazard ratio, 1.23; 95% CI, 1.06-1.31). Results were consistent across multiple subgroup and sensitivity analyses. In this cohort study of US adults, initiating oxycodone in patients treated with paroxetine or fluoxetine was associated with a small increased risk of opioid overdose.
Highlights
Opioid-related overdose deaths continue to impose an extensive and unabated public health burden in the United States.[1]
The adjusted incidence rate of opioid overdose in those using inhibiting selective serotonin reuptake inhibitor (SSRI) at the time of oxycodone initiation (9.47 per 1000 person-years) was higher than in those using other SSRIs (7.66 per 1000 person-years), indicating a greater risk of overdose among patients using CYP2D6inhibiting SSRIs
In this cohort study of US adults, initiating oxycodone in patients treated with paroxetine or fluoxetine was associated with a small increased risk of opioid overdose
Summary
Opioid-related overdose deaths continue to impose an extensive and unabated public health burden in the United States.[1] Between 1999 and 2019, more than half of all drug overdose deaths in the United States were attributed to opioids, with a substantial number involving prescription opioids.[2,3,4] In 2019, nearly a third of all opioid overdose deaths occurred in people taking prescription opioids.[5,6] Among the multiple risk factors associated with opioid overdose, a 2018 Surgeon General advisory warned that, even when opioid medications are used as prescribed, patients may be at higher risk of accidental overdose when using medications that can interact with opioids.[7] The advisory highlighted sedatives, such as benzodiazepines; opioids have the potential to interact, either pharmacokinetically or pharmacodynamically, with many other medications.[7,8,9,10] For the most part, the clinical impact of pharmacological drug-drug interactions on opioid-related adverse events, including overdose, is unknown
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