Trends in prescription opioid use and dose trajectories before opioid use disorder or overdose in US adults from 2006 to 2016: A cross-sectional study

Abstract

BackgroundWith governments’ increasing efforts to curb opioid prescription use and limit dose below the Centers for Disease Control and Prevention (CDC)-recommended threshold of 90 morphine milligram equivalents per day, little is known about prescription opioid patterns preceding opioid use disorder (OUD) or overdose. This study aimed to determine prescribed opioid fills and dose trajectories in the year before an incident OUD or overdose diagnosis using a 2005–2016 commercial healthcare database.Methods and findingsThis cross-sectional study identified individuals aged 18 to 64 years with incident OUD or overdose in the United States. We measured the prevalence of opioid prescription fills and trajectories of opioid morphine equivalent dose (MED) prescribed during the 12-month period before the diagnosis. Of 227,038 adults with incident OUD or overdose, 33.1% were aged 18 to 30 years, 52.9% were males, and 85.0% were metropolitan residents. Half (50.5%) of the patients had a diagnosis of chronic pain, 32.7% had depression, and 20.3% had anxiety. Overall, 79,747 (35.1%) patients filled no opioid prescription in the 12 months before OUD or overdose diagnosis, with the proportion significantly increasing between 2006 and 2016 (adjusted prevalence ratio, 1.86; 95% CI 1.79–1.93; P < 0.001). Patients without (versus with) prescribed opioids tended to be younger males and metropolitan and Northeast US residents. Of 145,609 patients who filled opioid prescriptions, 5 distinct prescribed daily dose trajectories preceding diagnosis emerged: consistent low dose (<3 mg MED, 34.6%), consistent moderate dose (20 mg MED, 27.3%), consistent high dose (150 mg MED, 15.0%), escalating dose (from <3 to 20 mg MED, 13.7%), and de-escalating dose (from 20 to <3mg MED, 9.4%). Overall, over two-thirds of patients with OUD or overdose with prescription opioids were prescribed a mean daily dose below 90 mg MED before diagnosis. Major limitations include the limited generalizability of the study findings and lack of information on out-of-pocket drug spending, race/ethnicity, and socioeconomic status of participants, which prevents analyses addressing these characteristics.ConclusionsIn this study, we found that absence of opioid prescription fills in the year before incident OUD or overdose diagnosis was prevalent, and the majority of the patients received prescription opioid doses below the risk threshold of 90 mg MED. An increasing proportion of high-risk patients could be missed by current programs solely based on opioid prescribing and dispensing information in this new era of limited access to prescription opioids.

Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare beneficiaries in the United States: A nested case–control study

“…Across the 4 identified groups, we observed a low dose range (mean daily dose between 0 to 20 daily MME) of prescribed opioids and less than 5% of older patients, the majority of whom were among the cases, receiving doses at or above the dose threshold of 90 daily MME. Compared to evidence observed in younger adults with ORAE [ 25 ], a lower dose range (0 to 20 daily MME versus 3 to 150 daily MME) and a lower proportion with ≥90 daily MME (2.4% versus 28.8%) was observed among older adults with a similar diagnosis of ORAE, suggesting that there is a unique opioid dosage pattern preceding the incident ORAE encounter in the older population.…”

“…The adverse effects of opioids defined by the E codes include any severe reactions to illicit opioids (i.e., heroin) or correct use of prescribed opioids (i.e., methadone, opioid antagonists, and other opioids) that lead to an emergency department or hospital visit. Consistent with prior studies [ 4 , 25 ], when identifying patients with incident ORAE encounter, we excluded ICD-10-CM codes that indicated “in remission” or “subsequent encounter.” The date of the first ORAE encounter represented the “index” date.…”

Addressing the context and consequences of substance use, misuse, and dependence: A global imperative

“…Analyzing 2005–2016 claims data, Yu-Jung Wei and colleagues [21] identified more than 200,000 adults with new claims related to opioid use disorder or overdose. They found that, by the end of the study period, nearly one-half had filled no opioid prescriptions in the 12 months prior to an incident opioid use disorder diagnosis or overdose.…”

Classification and visualization of longitudinal patterns of medication dose: An application to interferon‐beta‐1a and amitriptyline in patients with multiple sclerosis

“…Group‐based trajectory modelling (GBTM) is a semi‐parametric latent class approach to identify subgroups sharing similar patterns, that is, trajectories, in longitudinal data such as drug dose 4–6 . GBTM assumes that individual trajectories within class are homogeneous, which confers attractive computational properties over alternative latent class approaches 4 .…”

“…Recently, guidelines for the conducting of and reporting 7 on trajectory studies have been proposed to limit model misspecification 7 . Although GBTM have been routinely used to identify patterns of drug adherence, few studies 6,8,9 were focused on patterns of medication dose. For example, Wei et al identified five distinct patterns of opioid morphine dose prescribed during the year before an opioid use disorder or overdose, including low and escalating dose 6 …”