Association of Mental Health Conditions and Treatments With Long-term Opioid Analgesic Receipt Among Adolescents

Abstract

IMPORTANCE Adults with mental health conditions are more likely than those without to receive long-term opioid therapy. Less is known about opioid therapy among adolescents, especially those with mental health conditions. OBJECTIVE To examine associations between preexisting mental health conditions and treatments and initiation of any opioid and long-term opioid therapy among adolescents. DESIGN, SETTING, AND PARTICIPANTS A cohort of 1 224 520 incident opioid recipients without cancer diagnoses aged 14 to 18 years at first receipt was extracted from nationwide commercial health care claims data from January 1, 2003, to December 31, 2014. Analysis was conducted from August 19, 2016, to November 16, 2017. Associations between preexisting mental health conditions and treatments and any opioid receipt were examined by comparing recipients with nonrecipients matched on sex, calendar year and years of age of first enrollment, and months of enrollment (prior to the index month for recipients, ever for nonrecipients). Associations between preexisting mental health conditions and treatments and subsequent long-term opioid therapy were examined among recipients with at least 6 months' follow-up using Cox proportional hazards regressions adjusted for demographics. EXPOSURES Mental health condition diagnoses and treatments recorded in inpatient, outpatient, and filled-prescription claims prior to opioid receipt. MAIN OUTCOMES AND MEASURES Opioid receipt, defined as any opioid analgesic prescription claim, and long-term opioid therapy, defined as more than 90 days' supply within a 6-month window having no gaps in supply of more than 32 days. RESULTS Of the 1 224 520 new opioid recipients included, the median age at first receipt was 17 years (interquartile range, 16-18 years), and 51.1% were female. Median follow-up after first receipt was 625 days (interquartile range, 255-1268 days). Adolescents with anxiety, mood, neurodevelopmental, sleep, and nonopioid substance use disorders and most mental health treatments were significantly more likely to receive any opioid (odds ratios from 1.13 [95% CI, 1.10-1.16] for nonopioid substance use disorders to 1.69 [95% CI, 1.58-1.81] for nonbenzodiazepine hypnotics). Among the 1 000 453 opioid recipients (81.7%) who had at least 6 months' follow-up, the cumulative incidence of long-term opioid therapy was 3.0 (95% CI, 2.8-3.1) per 1000 recipients within 3 years after first opioid receipt. All preexisting mental health conditions and treatments were strongly associated with higher rates of long-term opioid therapy (adjusted hazard ratios from 1.73 [95% CI 1.54-1.95] for attention-deficit/hyperactivity disorder to 8.90 [95% CI, 5.85-13.54] for opioid use disorder). CONCLUSIONS AND RELEVANCE Commercially insured adolescents with many types of preexisting mental health conditions and treatments were modestly more likely to receive any opioid and were substantially more likely to subsequently transition to long-term opioid therapy relative to those without, although overall rates of long-te...

Associations of mental health and family background with opioid analgesic therapy: a nationwide Swedish register-based study

“…The substantial associations of pre-existing mental health conditions with LTOT are consistent with our previous results from US commercial healthcare insurance claims [51,52]. Other US studies have also found greater concurrent benzodiazepine and other sedative-hypnotic use among opioid recipients with mental health conditions [63,80].…”

“…We set censoring dates to six months prior to the end of available follow-up (i.e., the last date at which an individual was eligible to initiate a six-month LTOT window). Consistent with our previous studies, we report the cumulative incidence of opioid therapy receipt within 3 years as an index of absolute risk [51,52].…”

“…We identified inpatient and outpatient clinical diagnoses before 2007 for OUD and other SUD, suicide attempt or other self-injury, and attentiondeficit/hyperactivity, depressive, anxiety, schizophrenia spectrum, and bipolar disorders (eTable 3, Supplemental Digital Content, lists all ICD codes). We adapted ICD codes from prior opioid-related and register-based research [52,53]. As an alternative index of mental health, we also examined 2005-2006 receipt of psychoactive medications (i.e., antidepressants, antipsychotics, benzodiazepines, mood stabilizers, non-benzodiazepine zhypnotics, and medications used in the treatment of attention-deficit/hyperactivity disorder, OUD, and other SUD).…”

“…Studies of prescription in the US, often using commercial healthcare insurance records, have identified a number of predictors of opioid receipt. Critically, patients with pre-existing SUD and other mental health conditions are substantially more likely to receive long-term opioid therapy (LTOT) than are patients without those conditions [9,13,15,26,51,52]. Because such individuals may be at greater risk of harmful opioid outcomes, this phenomenon has been termed "adverse selection" [73].…”

Trajectories of pain and anxiety in a longitudinal cohort of adolescent twins

“…Among U.S. adolescents, anxiety disorders and benzodiazepine prescriptions are amongst the strongest predictors of transitioning from a first opioid prescription to long‐term opioid treatment (Quinn et al, 2018), and presence of chronic pain (without cancer diagnosis) doubles the cumulative incidence of long‐term opioid treatment within 3 years of filling the first opioid prescription (Quinn et al, 2018). Opioid treatment of chronic pain may entail serious harms (Chou et al, 2014) and the diversion and improper use of opioid analgesics resulted in an epidemic of addictions and overdose deaths (Volkow & McLellan, 2016).…”