More than 90% of patients who overdosed on prescription opioids continued to receive their prescriptions after the overdose, according to a study published in Annals of Internal Medicine.
“Prescribing guidelines specify that misuse of opioids and related adverse events are indications to discontinue long-term therapy,” Marc R. Larochelle, MD, MPH, of Boston Medical Center, and colleagues wrote. “However, patterns of treatment, including rates of continued prescribing, after an opioid overdose are unknown.”
To analyze opioid use after an overdose among patients receiving opioid therapy for noncancer pain, and to determine its association with repeated overdose, the researchers conducted a retrospective cohort study. They used the Optum database to collect inpatient, outpatient and pharmacy claims for patients from a large U.S. health insurer with members in all 50 states. Initially drawing from a cohort of 50 million commercially enrolled patients between May 2000 and December 2012, the researchers narrowed their field to a final cohort of 2,848 patients aged 18 to 64 years, who had a nonfatal opioid overdose during long-term opioid therapy for noncancer pain.
The primary outcome was identified as daily morphine-equivalent dosage (MED), or opioids dispensed from 60 days before to up to 730 days after the initial overdose. Dosages were classified as large, greater than or equal to 100 mg MED; moderate, 50 mg to less than 100 mg MED; low, less than 50 mg MED; or none, 0 mg MED.
Opioids were prescribed to 91% of patients after an overdose during a mean follow-up of 299 days. In addition, 7% of patients had a repeat opioid overdose. After 2 years, the cumulative incidence of repeated overdose was 17% (95% CI, 14%-20%) for patients prescribed high doses. For patients receiving moderate doses, the rate was 15% (95% CI, 10%-21%). For those with low doses, it was 9% (95% CI, 6%-14%), while the rate was 8% (95% CI, 6%-11%) among patients receiving no opioids.
The researchers also wrote that opioid discontinuation after an overdose was associated with a reduced risk for repeated overdose.
Of the 2,597 patients who continued to receive opioids after an overdose, the researchers were able to identify the primary prescriber during the periods before and after the overdose in 76% of cases. Of those patients, 61% received their opioids from the same prescriber they had before their initial overdose.
“Almost all members of a commercial insurance plan having opioid overdose continued to receive opioid prescriptions, with one-third receiving high-dose opioids over 2 years of follow-up,” Larochelle and colleagues wrote. “Patients receiving high dosages had more than twice the risk for repeated overdose. These findings suggest a meaningful opportunity to improve the safety of opioid prescribing through identification and treatment of persons having nonfatal overdose.”
In a related editorial, Jessica Gregg, MD, PhD, of Central City Concern, in Portland, Oregon, wrote that although it would be easy to attribute such prescription practices to poor care and bad decisions, other factors may be involved. These may include lack of prescriber knowledge of patient overdoses, lack of provider training and resources, the complexities involved when pain and opioid addiction overlap, and the knowledge among caregivers that ceasing opioid treatment can lead patients to seek illicit opioids.
“These are not quick fixes, and they will be difficult,” Gregg wrote. “However, if we do not act now to fix these systems of care, patients will continue to suffer — and even die — and physicians will continue to believe that they are powerless to stop it.” – by Jason Laday
Disclosures: Larochelle reports grants from the Health Resources and Services Administration. Please see the full study for a list of all other authors’ relevant financial disclosures. Gregg reports no relevant financial disclosures.