Repeat opioid overdose linked to continued use of high-dose prescriptions

1. From a cohort study of patients who had overdosed on opioids, 7% experienced a second overdose during a 2-year follow-up period.

2. Of those patients, those on a high dose opioid prescription had the highest rate of having a second overdose.

Evidence Rating Level: 2 (Good)

Study Rundown: The opioid addiction epidemic is a public health crisis in the United States, but the risks associated with continued use of prescription opioid painkillers after an initial overdose remain unclear. This retrospective cohort study sought to characterize the post-overdose changes in opioid usage patterns in patients being treated for chronic, non-cancer pain. The primary outcome was daily morphine-equivalent dose (MED) of opioid from 60 days before to, at most, 730 days after the initial overdose, and the time to repeated overdose was a secondary outcome. After overdosing, 91% of the cohort received one or more opioid prescription refills and only 7% experienced a second overdose, with those patients taking the highest dose opioids at the greatest risk. This study’s primary limitation was its design, which prevented the establishment of a causal link between opioid dosage after overdose and risk for a repeat overdose, and it only accounted for inpatient overdoses. While these limit the study’s generalizability, the findings suggest that practitioners should carefully consider their patients’ opioid use histories before prescribing another opioid for pain control.

Click to read the study, published today in the Annals of Internal Medicine

Relevant Reading: Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain

In-Depth [retrospective cohort]: A group of 2878 patients were followed from 90 days before their initial overdose to a median of 299 days after the overdose. At 60 days before the initial overdose, 46% of patients had a high dose (>100 mg MED), 22% had a moderate dose (50 to <100 mg MED) and 33% had a low dose (>0 to <50 mg MED) opioid prescription. At 31-90 days after the initial overdose, these percentages changed to 34% high dose, 17% moderate dose, and 37% low dose prescription, plus 12% had no opioid prescription. These numbers did not change significantly during the remainder of the follow-up period. Seven percent of patients overdosed a second time during follow-up. Of those patients with high dose, moderate dose, low dose, or no prescription of opioids, their second overdose rate was 17% (95% confidence interval, 14-20%), 15% (95%CI, 10-21%), 9% (95%CI, 6-14%) and 8% (95%CI, 6-11%) respectively. Based on a Cox model, high dose (adjusted hazard ratio, 2.57 [95%CI, 1.72-3.85]) and moderate dose (HR, 1.89 [95%CI, 1.18-3.04]) prescriptions were associated with increased risk for a second overdose. Of note, a daily benzodiazepine prescription was also associated with an increased risk for repeated overdose (HR, 1.74 [95%CI, 1.31-2.32]).

Image: PD

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