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Opioid overdose, death more likely in patients who use multiple prescribers, pharmacies

Patients exhibiting behaviors of opioid misuse, such as use of multiple prescribers and overlapping prescriptions, had a greater risk for subsequent overdose and death, according to results published in Annals of Internal Medicine.

“Providers are increasingly being expected to examine their patients’ opioid treatment histories before writing new opioid prescriptions,” Colleen M. Carey, PhD, from Cornell University, and colleagues wrote. “However, little evidence exists on how patterns of potential opioid misuse are associated with subsequent adverse outcomes nationally.”

Between 2008 and 2012, Carey and colleagues assessed opioid prescribing data from 627,391 Medicare beneficiaries to determine the association between patterns of potential opioid misuse and related adverse outcomes, including overdose and death.

The researchers measured opioid misuse based on drug quantity, overlapping prescriptions, use of multiple prescribers or pharmacies and use of out-of-state prescribers or pharmacies.

Patients exhibiting behaviors of opioid misuse, such as use of multiple prescribers and overlapping prescriptions, had a greater risk for subsequent overdose and death.

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Data indicated that 0.6% to 8.5% of beneficiaries showed signs of potential opioid misuse.

Participants with two, three or four prescribers or pharmacies had an increased risk for subsequent opioid overdose (adjusted absolute risk per 1,000 beneficiary-years = 3.5; 4.8; and 6.4, respectively), compared with those with one prescriber (adjusted absolute risk per 1,000 beneficiary-years = 1.9). Participants with greater opioid quantities also had a higher risk for overdose.

Any deviation from filling opioid prescriptions from a single prescriber at a single pharmacy significantly increased the risk for subsequent overdose, according to the researchers. All misuse measures were linked to subsequent opioid overdose and death.

These results remained after adjusting for average daily dose of opioids and patient demographics.

“We identified several potential markers of opioid misuse that were independently associated with an elevated risk for subsequent opioid overdose and death,” Carey and colleagues concluded. “Our results imply that a wide range of opioid use patterns beyond conventional definitions of possible opioid misuse may justify clinician attention.”

“Further research should examine the types of clinical interventions for patients with high-risk patterns of opioid use that might improve patient safety without causing unintended consequences, such as driving patients to illicit opioid use,” they added.

In an accompanying editorial, Lynn E. Fiellin, MD, and David A. Fiellin, MD, both from Yale University, wrote that the association between opioid prescribing and overdose and death risks found by Carey and colleagues should prompt new methods to enhance stewardship of controlled substances.

“As a start, an acute need exists to improve and customize [prescription drug monitoring programs] to better serve the needs of prescribers and, in turn, the patients to whom they provide care,” they wrote. – by Alaina Tedesco

Disclosure: Carey, Lynn Fiellin and David Fiellin report no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.