Opioid Prescriptions for Chronic Pain and Overdose

Abstract

Background Chronic opioid therapy for chronic non-cancer pain (CNCP) is increasingly common in community practice. Concomitant with this practice change, rates of fatal opioid overdose have increased. It is not known to what extent overdose risks are elevated among patients receiving medically prescribed chronic opioid therapy. Objective To estimate rates of opioid overdose and their association with average prescribed daily opioid dose among patients receiving medically prescribed chronic opioid therapy. Design Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at time of overdose. Setting Health maintenance organization. Patients Individuals (n=9940) who received 3+ opioid prescriptions within 90-days for CNCP between 1997 and 2005. Measurements Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes, non-fatal and fatal overdoses, were identified through diagnostic codes from inpatient and outpatient care and death certificates and confirmed by medical record review. Results Fifty-one opioid-related overdoses were identified, including six deaths. Compared to patients receiving 1-20mg of opioids per day (0.2% annual overdose rate), patients receiving 50-99 mg had a 3.7 fold increase in overdose risk (95% C.I. 1.5, 9.5) and a 0.7% annual overdose rate. Patients receiving 100mg or more per day had an 8.9 fold increase in overdose risk (95% C.I. 4.0, 19.7) and a 1.8% annual overdose rate. Limitations Increased overdose risk among patients on higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation. Conclusions Patients receiving higher doses of prescribed opioids are at increased risk of opioid overdose, underscoring the need for close supervision of these patients.

Provider Patient-Sharing Networks and Multiple-Provider Prescribing of Benzodiazepines

“…[25][26][27][28] Consistent with existing literature on the misuse of prescription drugs, we found that patients who had a psychiatrist in the care team were more likely to be exposed to multiple-provider prescriptions of benzodiazepines. 25,26 In-depth analysis of care team composition revealed that a significant proportion of patients who received benzodiazepine from a psychiatrist had a concurrent benzodiazepine prescription from a different provider (Table 3), signifying the need for greater care in treating and monitoring these patients. Patients with psychiatric illness often present with other medical conditions; the need for an integrated care approach that promotes collaboration among psychiatrists, PCPs, and other medical professionals caring for these patients is well recognized.…”

Opioid Overdose Deaths in the City and County of San Francisco: Prevalence, Distribution, and Disparities

“…5,6 Although there is a rich historical literature on the demographics and event-level characteristics of heroin overdose, 7,8 our understanding of recent trends of opioid overdose is limited and largely based on health system and non-urban regional analyses. [9][10][11][12][13][14] Prescription opioid overdose has been documented among rural and suburban non-Hispanic white men, [9][10][11][12][13][14][15] middle-aged females, 16,17 and those using psychotherapeutic drugs. 2,18 Patients in safety net healthcare systems, including the Veterans Administration 19 and Medicaid, 20 are more likely to die of prescription opioid overdose compared to the general population.…”

Drug Overdose in a Retrospective Cohort with Non-Cancer Pain Treated with Opioids, Antidepressants, and/or Sedative-Hypnotics: Interactions with Mental Health Disorders

“…We examined five categories for the mean daily MED (i.e., 0, 1-19, 20-49, 50-99, and ≥100 mg), similar to other studies. 9,10 For the first overdose, the mean daily MED was based on data from exactly 6 months before that event (Fig. 2).…”