Development of a Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in Veterans' Health Administration Patients

Abstract

ObjectiveDevelop a risk index to estimate the likelihood of life‐threatening respiratory depression or overdose among medical users of prescription opioids.Subjects, Design, and MethodsA case‐control analysis of administrative health care data from the Veterans’ Health Administration identified 1,877,841 patients with a pharmacy record for an opioid prescription between October 1, 2010 and September 30, 2012. Overdose or serious opioid‐induced respiratory depression (OSORD) occurred in 817. Ten controls were selected per case (n = 8,170). Items for an OSORD risk index (RIOSORD) were selected through logistic regression modeling, with point values assigned to each predictor. Modeling of risk index scores produced predicted probabilities of OSORD; risk classes were defined by the predicted probability distribution.ResultsFifteen variables most highly associated with OSORD were retained as items, including mental health disorders and pharmacotherapy; impaired drug metabolism or excretion; pulmonary disorders; specific opioid characteristics; and recent hospital visits. The average predicted probability of experiencing OSORD ranged from 3% in the lowest risk decile to 94% in the highest, with excellent agreement between predicted and observed incidence across risk classes. The model's C‐statistic was 0.88 and Hosmer–Lemeshow goodness‐of‐fit statistic 10.8 (P > 0.05).ConclusionRIOSORD performed well in identifying medical users of prescription opioids within the Veterans’ Health Administration at elevated risk of overdose or life‐threatening respiratory depression, those most likely to benefit from preventive interventions. This novel, clinically practical, risk index is intended to provide clinical decision support for safer pain management. It should be assessed, and refined as necessary, in a more generalizable population, and prospectively evaluated.

Opioid Overdose: Risk Assessment and Mitigation in Outpatient Treatment

“…Zedler and colleagues recently developed one such risk index in a VA population and found that in their study sample the predicted probability of overdose or serious opioid-induced respiratory depression was just 3% in those who were in their lowest risk-decile compared to 94% in their highest risk decile. (Zedler et al, 2015). However this work will need replication across different settings and populations to establish generalizability.…”

Prescription opioid use is common and associated with worse clinical outcomes in individuals with chronic liver disease

“…In addition, there are limited data on the independent effects of opioid use on relevant clinical outcomes in CLD. Owing to its altered physiology, prior studies have highlighted liver disease as a possible risk factor for overdose and other clinical outcomes such as hospital admissions and overall mortality . However, these small, single‐centre analyses are at risk for selection and measurement biases .…”

“…Owing to its altered physiology, prior studies have highlighted liver disease as a possible risk factor for overdose and other clinical outcomes such as hospital admissions and overall mortality. 5,6 However, these small, single-centre analyses are at risk for selection and measurement biases. [7][8][9][10][11] In order to address these important knowledge gaps, this study evaluates patterns of prescription opioid use, correlates of use, and clinical outcomes associated with opioid use among individuals with and without CLD in a large, nationally representative patient cohort.…”

Does trauma exposure predict prescription drug problems beyond the contribution of post-traumatic stress disorder and depression? An analysis of the Mind Your Heart cohort study

“…One area of concern in veterans is prescription drug problems, which is consistent with the growing misuse of prescription drugs globally 12–15 . Prescription drug problems are associated with significant morbidity and mortality in the veteran population 16–24 . Prescription drug problems are of particular concern in veterans due to the high prevalence of mental and physical health problems 16, 25 , such as chronic pain 19–21, 26, 27 .…”