Risk Factors For Opioid Overdose Research Articles

Take-Home Naloxone Access and Use among Older Adults Living with Pain: A Scoping Review.

Opioids are a common treatment for older adults living with pain. Given high rates of polypharmacy and chronic comorbidities, older adults are at risk of opioid overdose. Evidence is now available that take-home naloxone (THN) supports reduction of opioid-related harms. It is unknown what THN initiatives are available for older adults, especially those living with chronic pain. To summarize the literature regarding THN, with a focus on older adults using opioids for pain, including facilitators of and barriers to THN access, knowledge gaps, and pharmacist-led initiatives. A scoping review, guided by an established framework and PRISMA-ScR guidelines, was performed. Methods involved searching 6 bibliographic databases (MEDLINE, Embase, Scopus, APA PsycINFO, Web of Science Core Collection, and PubMed), reference harvesting, and citation tracking. Searches were conducted up to March 2023, with no date limits applied; only English publications were included. Study eligibility was determined according to preset criteria, including age; discrepancies were resolved by discussion and consensus. Data were extracted and categorized through thematic analysis. Four studies met the eligibility criteria. All 4 studies detailed THN programs in primary care settings involving older adults taking opioids for pain management. Two of the studies highlighted patient-specific risk factors for opioid overdose, including concomitant use of benzodiazepines and/or gabapentinoids, mean morphine milligram equivalents per day of at least 50, and previous opioid overdose. Two of the studies assessed patient knowledge of opioid overdose management and attitudes toward THN. Educational programs increased patients' interest in THN. The literature about THN for older adults living with pain is limited, and no literature was found on pharmacist-led initiatives in this area. Future research on THN provision for older adults, including pharmacist-led initiatives, could help to optimize care for older adults living with pain.

Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies.

Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids. We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs). Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose. We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/).

EPH37 The Role of Prescribed Controlled Substance Acquisition As Potential Triggers of Opioid Overdose: A Case-Crossover Study

The role of prescribed opioids and benzodiazepines as risk factors for opioid overdose (OOD) are well established, however, their role as potential ‘triggers’ of OOD has not been formally investigated. The objective of this study was to utilize a case-crossover design to evaluate the temporal relationship between controlled substance acquisition and OOD.

Intention to get naloxone among patients prescribed opioids for chronic pain

BackgroundPrescription opioids have been increasingly prescribed for chronic pain while the opioid-related death rates grow. Naloxone, an opioid antagonist, is increasingly recommended in these patients, yet there is limited research that investigates the intention to get naloxone. This study aimed to investigate intention toward getting naloxone in patients prescribed opioids for chronic pain and to assess the predictive utility of the theory of reasoned action (TRA) constructs in explaining intention to get naloxone.MethodsThis was a cross-sectional study of a panel of U.S. adult patients prescribed opioids for chronic pain using a Qualtrics®XM survey. These patients participated in the study during February to March 2020. The online internet survey assessed the main outcome of intention to get naloxone and constructs of TRA (attitudes and subjective norms); additional measures assessed the characteristics of patients’ opioid overdose risk factors, knowledge of naloxone, and their demographics. The relationship between TRA constructs, namely, attitudes and subjective norms, and the intention variable was examined using logistic regression analyses with the intention outcome contrasted as follows: high intention (scores ≥ 5) and non-high intention (scores < 5).ResultsA total of 549 participants completed the survey. Most of them were female (53.01%), White or Caucasian (83.61%), non-Hispanic (87.57%) and had a mean age of 44.16 years (SD = 13.37). Of these, 167 (30.42%) had high intention to get naloxone. The TRA construct of subjective norm was significantly associated with increased likelihood of higher intentions to get naloxone (OR 3.04, 95% CI 2.50–3.70, P < 0.0001).ConclusionsOur study provides empirical support of the TRA in predicting intention to get naloxone among chronic pain patients currently taking opioids. Subjective norms significantly predicted intention to get naloxone in these patients. The interventions targeting important reference groups of these patients would have greater impact on increasing intention to get naloxone in this population. Future studies should test whether theory-based interventions focusing on strengthening subjective norms increase intention to get naloxone in this population.

Increasing Naloxone Co-Prescribing Among At-Risk Individuals: Evaluation of a Quality Improvement Project in a Large Health System

Background: Naloxone availability and early administration is key in preventing death following opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of at-risk patients had naloxone prescriptions Methods: Included in this study were all patients of MaineHealth, a health system comprising 9 hospitals and 30 primary care practices, serving approximately 1.1 million patients. Between 2017 and 2020, we implemented several system-wide quality improvement interventions to increase rates of naloxone co-prescribing among at-risk individuals. Risk factors included prescribed opioids ≥50 morphine milligram equivalents, concurrent prescriptions for opioids and benzodiazepines or sedative/hypnotics, a diagnosis of substance use disorder, or a history of opioid overdose. Our interventions included (1) a standing order for naloxone in the hospital pharmacy, (2) in-person naloxone trainings for all clinical and non-clinical primary care staff, (3) online training modules, (4) guidelines on naloxone co-prescribing sent via email, and (5) automated alerts in the electronic medical record (EMR). To evaluate these interventions, the EMR for, was queried for patients with one or more risk factors for opioid overdose, and whether they had naloxone on their medication list between 2017 and 2020. Results: Over the course of the study period, overall rate of naloxone co-prescribing system-wide increased from 0.4% to 26% of patients. Automatic EMR alerts were associated with an increase of 4.5%, the largest single-quarter increase. Online education modules and guideline dissemination were associated with smaller increases of 0.9% and 3% in the two quarters following their implementation. In-person trainings and making naloxone available without a prescription were followed by Conclusions: Our most effective intervention was automatic alerts in the EMR, while e online trainings and guidelines produced modest effects. A notable increase was also seen in one hospital system whose entire leadership and staff deliberately prioritized increasing naloxone access. Even with these gains, we have not yet achieved adequate co-prescribing across our system.

Risky alcohol use among patients dispensed opioid medications: A clinical community pharmacy study

BackgroundIncluded among the significant risk factors for opioid overdose is concomitant use of other central nervous system depressants, particularly alcohol. Given the continued expansion of community pharmacy in the continuum of care, it is imperative to characterize alcohol use among pharmacy patients dispensed opioids in order to establish a foundation for identification and intervention in these settings. MethodsThis secondary analysis utilized data from a one-time, cross-sectional health assessment conducted among patients dispensed opioid medications in 19 community pharmacies in Indiana and Ohio. Adult, English speaking, patients not receiving cancer care who were dispensed opioid medications were asked to self-report alcohol and substance use, behavioral and physical health, and demographic information. Descriptive and logistic regression analyses were employed to characterize alcohol use/risky alcohol use and patient characteristics associated therewith. ResultsThe analytical sample included 1494 individuals. Participants were on average 49 years of age (Standard Deviation=14.9)—with 6% being persons of color (n = 89). Weekly drinking was reported by 18.1% (n = 204) and daily drinking was reported by 6.8% (n = 77) of the study sample, with a total of 143 (9.6%) participants reporting moderate/high risk drinking.Males (Adjusted Odds Ratio [AOR]=1.94, 95% CI=1.3,2.9), those with higher pain interference (AOR=1.44, 95% CI=1.0,2.0), overdose history (AOR=1.93, 95% CI=1.1,3.5), sedative use (AOR=2.11, 95% CI=1.3,3.5), and tobacco use (AOR=2.41, 95% CI=1.6,3.7) had increased likelihood of moderate/high risk alcohol use (all p < 0.05). ConclusionsMedication labeling and clinical guidelines clearly indicate that patients should abstain from concomitant use of opioids and alcohol. This study has identified rates and associated risk factors of risky alcohol use among a clinical sample of community pharmacy patients dispensed opioid medications. Continuing this line of research and potential clinical service development has the ability to improve patient safety through addressing a significant gap within the current opioid epidemic.

Naloxone Dispensing in Patients at Risk for Opioid Overdose After Total Knee Arthroplasty Within the Veterans Health Administration.

Naloxone prescribing among patients undergoing surgery is not well described. This cohort study was designed to examine patients' risk factors for opioid overdose and their association with naloxone prescribing among veterans undergoing total knee arthroplasty (TKA) after a systemwide Overdose Education and Naloxone Distribution (OEND) initiative. A retrospective analysis of Veterans Health Administration (VHA) records was performed and consisted of 38,011 veterans undergoing primary TKA from 2013 to 2016. Patient overdose risk was determined using a validated risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) based on patient diagnoses, health care utilization, and prescription drug use. Naloxone dispensing was examined from the year before surgery until 7 days after discharge. These rates were examined the year prior to implementation of a national OEND initiative (2013), the year of implementation (2014), and 2 years following implementation (2015-2016). In 2013, 3.3% of patients presenting for TKA had moderate or high risk for overdose and none were prescribed naloxone. By 2016, after OEND implementation, 2.2% of patients presenting for TKA had moderate or high risk for overdose, but only 10.9% of the moderate-risk and 12.7% of the high-risk patients were prescribed naloxone. Patients presenting for TKA routinely have risk factors for opioid overdose and significant proportions are at moderate or high risk for overdose. Despite this, most patients at moderate and high risk do not receive perioperative naloxone. Risk mitigation strategies using validated tools such as RIOSORD may help identify surgical patients at greatest risk for opioid overdose who could benefit from OEND.

Comparing person-level matching algorithms to identify risk across disparate datasets among patients with a controlled substance prescription: retrospective analysis.

BackgroundThe opioid epidemic in the United States has precipitated a need for public health agencies to better understand risk factors associated with fatal overdoses. Matching person-level information stored in public health, medical, and human services datasets can enhance the understanding of opioid overdose risk factors and interventions.ObjectiveThis study compares approximate match versus exact match algorithms to link disparate datasets together for identifying persons at risk from an applied perspective.MethodsThis study used statewide prescription drug monitoring program (PDMP), arrest, and mortality data matched at the person-level using an approximate match and 2 exact match algorithms. Impact of matching was assessed by analyzing 3 independent concepts: (1) the prevalence of key risk indicators used by PDMP programs in practice, (2) the prevalence of arrests and fatal opioid overdose, and (3) the performance of a multivariate logistic regression for fatal opioid overdose. The PDMP key risk indicators included (1) multiple provider episodes (MPE), or patients with prescriptions from multiple prescribers and dispensers, (2) high morphine milligram equivalents (MMEs), which represents an opioid’s potency relative to morphine, and (3) overlapping opioid and benzodiazepine prescriptions.ResultsPrevalence of PDMP-based risk indicators were higher in the approximate match population for MPEs (n = 4893/1 859 445 [0.26%]) and overlapping opioid/benzodiazepines (n = 57 888/1 859 445 [4.71%]), but the exact-basic match population had the highest prevalence of individuals with high MMEs (n = 664/1 910 741 [3.11%]). Prevalence of arrests and deaths were highest for the approximate match population compared with the exact match populations. Model performance was comparable across the 3 matching algorithms (exact-basic validation area under the receiver operating characteristic curve [AUC]: 0.854; approximate validation AUC: 0.847; exact + zip validation AUC: 0.826) but resulted in different cutoff points balancing sensitivity and specificity.ConclusionsOur study illustrates the specific tradeoffs of different matching methods. Further research should be performed to compare matching algorithms and its impact on the prevalence of key risk indicators in an applied setting that can improve understanding of risk within a population.

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

PDG1 Opioid Overdose Risk Factors and Naloxone Prescribing Among Adults Enrolled in Mississippi Medicaid

Naloxone, which is a safe, rapid-acting, and easy to use opioid antagonist medication, has become a critical tool to prevent opioid overdose deaths in recent years. The objective of this study was to describe naloxone use among patients receiving opioids enrolled in Mississippi Medicaid. A retrospective analysis was conducted using Mississippi Medicaid data from August 2018 to August 2020. Beneficiaries aged 18 and older and received opioid prescriptions were included. Receiving naloxone was defined as patients receiving any outpatient fill for a naloxone prescription. Risk factors for opioid overdose emphasized in the CDC guidelines were identified for eligible beneficiaries. A chi-square test, Fisher’s Exact test, or t-test was used to analyze differences in naloxone use among various demographic variables and risk factors. A total of 113,739 beneficiaries receiving opioids were included. Of these beneficiaries, 0.52% (597 beneficiaries) received naloxone. Beneficiaries who were between 46 and 65 years of age, African American, and covered by Magnolia health plan were more likely to receive naloxone compared with other groups (p < 0.001). Higher percentages of naloxone users had risk factors for overdose including high Morphine Equivalent Daily Dose (MEDD) use, long-term opioid use, concomitant use of benzodiazepine, concomitant use of antipsychotic, high-risk diagnosis (i.e., alcohol dependence, opioid dependence, other substance abuse dependence, and depression), and history of opioid overdose compared with non-naloxone users (p < 0.001). This study provided evidence on naloxone fills among Medicaid beneficiaries receiving opioids. The results showed that the use of naloxone was still very low, even after the emphasis of considering naloxone use for patients with risk factors in 2018. Further studies are needed to investigate the barriers contributing to the low rate of naloxone use, and interventions are needed for improving the appropriate use of naloxone.

New and Emerging Opioid Overdose Risk Factors.

Purpose of ReviewThe purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis.Recent FindingsBoth a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose.SummaryThe opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.

Promoting Opioid Awareness Through a Union-Based Peer Training Model.

Work factors, including physical job demands, appear to be risk factors for opioid overdoses. We collaborated with unions representing workers in high-risk occupations and offered resources to develop tailored educational interventions for their members. An ironworkers' local, a statewide nurses' union, and a Teamsters local union participated, at levels higher than we had anticipated. The three unions trained 285 workers, including apprentices, stewards, and those nearing retirement. Short surveys assessed pre- and post-training knowledge, attitudes, confidence in helping others, and related domains. Seventy percent of respondents reported heavy or very heavy physical demands at work, and one-half had experienced work-related pain. After training, participants reported more knowledge about opioids, less concern about stigma related to help-seeking, and more ability to provide help to a co-worker struggling with opioids. Peers with recovery experience provided a unique contribution to training. Tailored job-specific and peer-delivered educational interventions may be able to reduce the potential impact of opioids on working people.

Diagnosed Opioid Use Disorder Among Older Adults: Complex Comorbidity and Management Challenges

In the face of a widespread opioid epidemic and many policy changes affecting opioid access and management, it is important to understand the prevalence and characteristics of diagnosed opioid use disorder in older people and their implications for effective management of this high-risk population. We examined these issues in an ~40% random sample of Medicare beneficiaries with Part D coverage. In 2017, .8% of beneficiaries ages 65+ were diagnosed with OUD (opioid abuse or dependence diagnoses), an increase from .5% in 2015. The late-2015 transition from ICD-9 to ICD-10 may have contributed to this change, but the rate also increased post-ICD-10 by 9.1% from 2016-2017. The profile of individuals diagnosed with OUD reveals a population with complex comorbidity and multiple health challenges: 45% were diagnosed with major depression, 7% with alcohol disorders, 45% with anxiety, 8% with hepatitis C, 26% with cancer, 38% with COPD and 19% with pneumonia (risk factors for opioid overdose), 56% with diabetes and 27% with heart failure. 97% were diagnosed with pain conditions, 85% received opioid prescriptions, and 38% received benzodiazepine prescriptions. These patients represent complex and potentially competing challenges in concurrent management of pain, opioid use disorder, multi-substance use and opioid use disorder. Development of effective, integrated care models to simultaneously address these interrelated problems in this high-risk population should be informed by a closer focus on their multiple needs and monitoring of the adequacy of health system response.

Opioid Overdoses Among High‐Risk Medicaid Members: Health care Cost, Service Utilization, and Risk Factor Analysis

AbstractResearch ObjectiveTo identify risk factors associated with opioid overdoses among three high‐risk populations of Medicaid members related to cost and service utilization.Study DesignRepeated cross‐sectional study using five years of Massachusetts Medicaid (MassHealth) claims and state agency data.Population StudiedMassHealth members aged 11‐64 years considered to be high‐risk (homeless, unstably housed, and/or criminal justice‐involved) and in need of support services, especially those with extensive behavioral health (BH) needs. These three populations were identified as being particularly vulnerable to non‐fatal and/or fatal opioid overdoses.Principal FindingsMassHealth members who were both justice‐involved and unstably housed were at much higher risk of an opioid overdose than the MassHealth population overall, especially those with a substance use disorder (SUD) or a serious mental illness (SMI). Experiencing both homelessness and justice involvement substantially compounded members’ non‐fatal overdose risk, regardless of BH diagnosis. Co‐occurring SUD/SMI was a key driver of high overdose prevalence, particularly among the justice‐involved. Compared to MassHealth members in general, those with justice involvement and unstable housing had costs that were 50‐65% higher; members who experienced homelessness had triple the costs. Health care service use both before and after an overdose was relatively low, including the timeframe between multiple non‐fatal overdoses. In multivariate analyses, all three high‐risk factors (i.e., populations) were significantly related to an increased opioid overdose risk after controlling for additional risk factors (BH diagnoses, chronic medical conditions, and demographic characteristics). Males and whites were more likely to have an opioid overdose; those with diabetes or hypertension were less likely. These results were similar when assessing various opioid overdose outcomes (non‐fatal and/or fatal).ConclusionsThese findings helped inform MassHealth’s understanding of its members’ experiences regarding medical and BH services, especially among high‐risk populations with an opioid overdose. The identification of risk factors most predictive of a subsequent overdose may help address the needs of these high‐risk groups. For most of the populations studied, prevalence of co‐occurring BH diagnoses was much higher than MassHealth members in general and appeared to impact opioid overdose rates. Most members received services for 1‐2 months in both the pre‐ and post‐overdose periods; service use was relatively low in the year following a non‐fatal overdose, suggesting retention was also low. Multivariate analyses consistently showed that gender and race were significantly associated with increased overdose risk.Implications for Policy or PracticeUnderstanding opioid overdose risk factors and identifying service utilization gaps and missed opportunities are important. As payment reforms evolve under the umbrella of accountable care organizations, BH community partnership models are key for collaborating with health care and social service providers, and community resources for care management, care coordination, and referrals to support services. Our study initially developed an in‐depth descriptive analysis of individuals with SUD, SMI, or both identified as being at high risk for an opioid overdose. Understanding service trajectory and outcomes through additional analyses was critical for planning and prioritizing appropriate services. As payors are actively making decisions about effective systems of care, they are particularly interested in understanding the need for community‐based and residential services, particularly for those with housing instability and/or criminal justice involvement.Primary Funding SourceMassachusetts Medicaid Office.

Incidence rates of and risk factors for opioid overdose in new users of prescription opioids among US Medicaid enrollees: A cohort study.

To measure incidence rates of and risk factors for opioid overdose among new users of prescription opioids in the Medicaid population. A cohort study using Medicaid claims from four states (1999-2012) among adults continuously enrolled in Medicaid for ≥3 years free of opioid prescriptions and opioid overdose before cohort entry. Exposure and outcome of interest were prescription opioid use and apparent incident opioid overdose identified in inpatient and outpatient claims (sensitivity ≈ 97%; positive predictive value ≈ 87%), respectively. Among new prescription opioid users (1 336 140 persons; 246 466 person-years), the overall opioid overdose incidence rate per 100 000 person-years was 247.1 (95% confidence interval [CI], 227.5-266.7), with 251.0 (CI, 188.6-313.5) in 2002 and 225.5 (CI, 142.0-309.0) in 2012. A lower hazard for opioid overdose was seen for age 65-80 years (adjusted hazard ratio [HR], 0.50; CI, 0.37-0.66) and 80-100 years (0.35; 0.23-0.52) vs 18-35 years; females (0.79; 0.67-0.93) vs males; and other/unknown race/ethnicity (0.71; 0.54-0.93) vs whites. A higher hazard was seen for initial opioid dose in morphine milligram equivalents (MMEs), 50-100 MME/day (1.52; 1.24-1.86) and >100 MME/day (1.98; 1.55-2.53), vs <50 MME/day; prior diagnosis of substance use disorders (2.30; 1.91-2.79) or mental health conditions (1.75; 1.47-2.08); and prior prescriptions for benzodiazepines (1.43; 1.13-1.81). In Medicaid enrollees in four study states during 2002 to 2012, opioid overdose incidence rate per 100 000 person-years among apparent new users of prescription opioids was 247.1, with 251.0 in 2002 and 225.5 in 2012. Younger ages, white race/ethnicity, higher MME opioid daily doses, prior substance use disorders, mental health conditions, and benzodiazepine prescriptions were associated with a higher risk of opioid overdose incidence.

Risk of Overdose with Exposure to Prescription Opioids, Benzodiazepines, and Non-benzodiazepine Sedative-Hypnotics in Adults: a Retrospective Cohort Study

Concurrent use of benzodiazepines in opioid users has been linked to a higher risk of an emergency room visit or inpatient admission for opioid overdose and death from drug overdose. Further research is needed to confirm the findings and analyze contributing risk factors for opioid overdoses in a large commercially insured population. To estimate the risk of opioid overdose associated with opioid users exposed to various combinations of opioid, benzodiazepine, and non-benzodiazepine sedative-hypnotic therapy. To identify other factors that are associated with increased risk for opioid overdose. Retrospective cohort study. New start adult users of opioids, defined as naïve to opioids for 6 months, in Kaiser Permanente California regions from January 2013 through September 2017. Inpatient or emergency department admissions due to opioid-related overdose. A total of 2,241,530 patients were included in this study. Patients exposed to opioids, benzodiazepines, and non-benzodiazepine sedative-hypnotics at any point during their follow-up were 60% more likely to overdose than those who were only exposed to opioids (p < 0.0001). Those exposed to opioids and benzodiazepines were 20% more likely to have an opioid-related overdose than those exposed to opioids only (p < 0.0001). Significant risk factors for opioid overdose included exposure to all three medication classes, higher opioid dosage strengths, elderly age (age ≥ 65 years), history of previous overdose, and substance use disorder. Results from this study demonstrate a significant increase in risk of opioid overdose in patients exposed to combinations of sedative-hypnotics with opioids compared to those only taking opioids. Findings from this study provide evidence that opioids should be avoided in combination with benzodiazepines and non-benzodiazepine sedative-hypnotics, used at the lowest dose possible, and used with caution in the elderly, those with previous history of overdose, and those with substance use disorder at baseline.

Association of Opioid Overdose Risk Factors and Naloxone Prescribing in US Adults.

Prescribing naloxone to patients is a key strategy to prevent opioid overdoses, but little is known about the reach of naloxone prescribing. Determine patient factors associated with receiving naloxone and trends over time in patients with key overdose risk factors. Retrospective observational study. Using the Clinformatics DataMart, a US-wide health insurance claims dataset, we compared adults who received opioids and naloxone (opioid+naloxone) from January 2014 to June 2017 with adults who received opioids without naloxone (opioids only), matched on gender, age ± 5 years, month/year of opioid fill, and number of opioid claims. Key patient-level opioid overdose risk factors included receipt of high-dosage opioids, concurrent benzodiazepines, history of opioid and other substance use disorders, and history of opioid overdose. We included 3963 opioid+naloxone and 19,815 opioid only patients. Key factors associated with naloxone fills included high opioid daily dosage (50 to < 90 morphine milligram equivalents (MME): AOR = 2.43, 95% CI 2.15-2.76 and ≥ 90 MME: AOR = 3.94, 95% CI 3.47-4.46; reference: < 50 MME), receiving concurrent benzodiazepines (AOR = 1.27, 95% CI 1.16-1.38), and having a diagnosis of opioid use disorder (AOR = 1.56, 95% CI 1.40-1.73). History of opioid overdose was not associated with naloxone (AOR = 0.92, 95% CI 0.74-1.15). The percent of patients receiving naloxone increased, yet less than 2% of patients in any of the key overdose risk factor groups received naloxone by the last 6 months of the study period. Naloxone prescribing has increased and was more likely to be co-prescribed to patients with some risk factors for overdose. However, overall prescribing remains minimal. Additional efforts are needed across health systems to increase naloxone prescribing for patients at risk for opioid overdose.

Rates, knowledge and risk factors of non-fatal opioid overdose among people who inject drugs in India: A community-based study.

Non-fatal opioid overdose (NFOO) predicts future fatal opioid overdose and is associated with significant morbidity. There is limited literature on the rates and risk factors for NFOO in people who inject drugs (PWID) from India. We aimed to study the rates of NFOO and documented risk factors for NFOO, as well as knowledge-level of NFOO among PWID from India. Community-based, cross-sectional and observational study. We interviewed 104 adult male participants receiving HIV prevention services. Drug use patterns, rates of NFOO and opioid overdose risk factors, knowledge about opioid overdose and its management were assessed. The mean age of the participants was 27.9 years. The most common opioid used for injecting was heroin followed by buprenorphine. About 45% (n = 47) participants had experienced an opioid overdose at least once in their lifetime. Around 25% (n = 26) participants had overdosed in the past year, while 21% (n = 22) participants had overdosed within the past 3 months. The majority had risk factors that could predispose them to NFOO. No participant was aware of the use of naloxone for opioid overdose. The rates of NFOO as well as risk factors for overdose among PWID from India are high, with poor knowledge on overdose management. There is urgent need for a program to prevent and manage opioid overdose among PWID in India.

Opioid mortality in rural communities

Opioid mortality has become a significant medical and economic burden in the UnitedStates, accounting for over 66.3% of drug-related overdoses and $78 billion dollars in healthcare costs. The current US “opioid crisis” has continued to grow with an estimated 2.5 millionpatients being diagnosed with opioid use disorders in 2016. In response, policy makers andgovernment agencies have initiated several programs to mitigate the adverse effects of opioidsthrough expanding access and delivery of evidenced-based treatment and rehabilitationprograms. Rural communities remain significant risk factors for opioid overdose and mortalityin areas lacking access to opioid therapy. Despite measures to provide access to rehabilitationand medical therapy, the opioid-related mortality rate in rural areas has increased significantlydue to greater opioid prescriptions in these areas, an out-migration of young adults, greaterrural social and kinship network connections, and economic stressors. However, limitedopioid-related mortality data in rural regions, such as West Texas, impede further analysisand investigation into effective programs for preventing and treating opioid overdoses in thesecommunities.

Capsule Commentary on Lin et al., "Association of Opioid Overdose Risk Factors and Naloxone Prescribing in US Adults.

Capsule Commentary on Lin et al., "Association of Opioid Overdose Risk Factors and Naloxone Prescribing in US Adults.