Understanding Risk Factors for Opioid Overdose in Clinical Populations to Inform Treatment and Policy

Abstract

Overdoses involving opioid analgesics represent a significant public health problem in the United States. We reviewed the literature on risk factors for overdose, with a focus on studies that examine clinical populations of patients receiving opioids for pain and potential risk factors for overdose in these populations. A structured review resulted in 15 articles published between 2007 and 2015 that examined risk factors for fatal and nonfatal overdose in patients receiving opioid analgesics. Opioid dosage was the factor most consistently analyzed and also associated with increased risk of overdose. Other risk factors include concurrent use of sedative-hypnotics, use of extended-release/long-acting opioids, and the presence of substance use and other mental health disorder comorbidities. Future research is needed to better characterize populations taking opioids for pain to help clarify discrepancies between existing studies and identify previously unexplored risk factors for overdose. Given that policy and clinical practice have shifted as a result of prior studies reviewed here, further efforts in understanding patient groups and opioid-related prescribing practices associated with overdose risk have great potential to impact policy and practice in the treatment of pain while improving the safety around opioid prescribing.

Long‐term opioid therapy definitions and predictors: A systematic review

“…Similarly, patients may also switch between long and short acting opioids during opioid use. Although technically reflective of LTOT, measures that do not account for these characteristics may not identify high‐risk populations . For example, identifying patients with doses above recommended thresholds (more than 90 MME) during LTOT allows providers to identify patients who could benefit from tapering opioid doses …”

Using prescription monitoring program data to characterize out‐of‐pocket payments for opioid prescriptions in a state Medicaid program

“…First, there is a growing literature on the development and refinement of indicators of high‐risk opioid use, misuse, or abuse and diversion. Studies document the frequency and harms associated with certain opioid misuse indicators such as doctor/pharmacy shopping or concurrent opioid use . Several organizations suggest that out‐of‐pocket payment is an indicator of misuse, but few studies have examined this because of inherent data limitations .…”

“…This pattern was highest with several opioids with high abuse potential and other indicators of misuse or diversion. Future research should be directed at assessing the relationship between out‐of‐pocket payments and adverse patient outcomes such as overdose . State PDMPs would benefit from uniformly collecting these payment source data for programmatic and epidemiologic purposes.…”

Prescription Opioid Use among Adults with Mental Health Disorders in the United States

“…Such a relationship is particularly concerning because mental illness is also a prominent risk factor for overdose and other adverse opioid-related outcomes. 24,25 Thus, the expectation would be that physicians would be more conservative with their prescribing behaviors in the setting of mental illness and favor nonopioid alternatives. The ability to identify populations that may use prescription opioids independent of pain would be of strategic importance for mitigating potential risk at a population health level.…”