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Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015.
J Gen Intern Med. 2018 09; 33(9):1512-1519.JG

Abstract

BACKGROUND

Potentially inappropriate prescribing (PIP) may contribute to opioid overdose.

OBJECTIVE

To examine the association between PIP and adverse events.

DESIGN

Cohort study.

PARTICIPANTS

Three million seventy-eight thousand thirty-four individuals age ≥ 18, without disseminated cancer, who received prescription opioids between 2011 and 2015.

MAIN MEASURES

We defined PIP as (a) morphine equivalent dose ≥ 100 mg/day in ≥ 3 months; (b) overlapping opioid and benzodiazepine prescriptions in ≥ 3 months; (c) ≥ 4 opioid prescribers in any quarter; (d) ≥ 4 opioid-dispensing pharmacies in any quarter; (e) cash purchase of prescription opioids on ≥ 3 occasions; and (f) receipt of opioids in 3 consecutive months without a documented pain diagnosis. We used Cox proportional hazards models to identify PIP practices associated with non-fatal opioid overdose, fatal opioid overdose, and all-cause mortality, controlling for covariates.

KEY RESULTS

All six types of PIP were associated with higher adjusted hazard for all-cause mortality, four of six with non-fatal overdose, and five of six with fatal overdose. Lacking a documented pain diagnosis was associated with non-fatal overdose (adjusted hazard ratio [AHR] 2.21, 95% confidence interval [CI] 2.02-2.41), as was high-dose opioids (AHR 1.68, 95% CI 1.59-1.76). Co-prescription of benzodiazepines was associated with fatal overdose (AHR 4.23, 95% CI 3.85-4.65). High-dose opioids were associated with all-cause mortality (AHR 2.18, 95% CI 2.14-2.23), as was lacking a documented pain diagnosis (AHR 2.05, 95% CI 2.01-2.09). Compared to those who received opioids without PIP, the hazard for fatal opioid overdose with one, two, three, and ≥ four PIP subtypes were 4.24, 7.05, 10.28, and 12.99 (test of linear trend, p < 0.001).

CONCLUSIONS

PIP was associated with higher hazard for all-cause mortality, fatal overdose, and non-fatal overdose. Our study implies the possibility of creating a risk score incorporating multiple PIP subtypes, which could be displayed to prescribers in real time.

Authors+Show Affiliations

RAND Corporation, Boston, MA, USA. arose@rand.org. Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA. arose@rand.org.Massachusetts Department of Public Health, Boston, MA, USA.Tufts University School of Medicine, Boston, MA, USA.Massachusetts Department of Public Health, Boston, MA, USA.Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA. Massachusetts Department of Public Health, Boston, MA, USA.Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.RAND Corporation, Pittsburgh, PA, USA. University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.Tufts University School of Medicine, Boston, MA, USA. Tufts Clinical and Translational Sciences Institute, Boston, MA, USA.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

29948815

Citation

Rose, Adam J., et al. "Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015." Journal of General Internal Medicine, vol. 33, no. 9, 2018, pp. 1512-1519.
Rose AJ, Bernson D, Chui KKH, et al. Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015. J Gen Intern Med. 2018;33(9):1512-1519.
Rose, A. J., Bernson, D., Chui, K. K. H., Land, T., Walley, A. Y., LaRochelle, M. R., Stein, B. D., & Stopka, T. J. (2018). Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015. Journal of General Internal Medicine, 33(9), 1512-1519. https://doi.org/10.1007/s11606-018-4532-5
Rose AJ, et al. Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015. J Gen Intern Med. 2018;33(9):1512-1519. PubMed PMID: 29948815.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015. AU - Rose,Adam J, AU - Bernson,Dana, AU - Chui,Kenneth Kwan Ho, AU - Land,Thomas, AU - Walley,Alexander Y, AU - LaRochelle,Marc R, AU - Stein,Bradley D, AU - Stopka,Thomas J, Y1 - 2018/06/14/ PY - 2018/05/08/received PY - 2018/06/05/accepted PY - 2018/06/05/revised PY - 2018/6/28/pubmed PY - 2019/11/23/medline PY - 2018/6/28/entrez KW - mortality KW - opioids KW - overdose KW - potentially inappropriate prescribing SP - 1512 EP - 1519 JF - Journal of general internal medicine JO - J Gen Intern Med VL - 33 IS - 9 N2 - BACKGROUND: Potentially inappropriate prescribing (PIP) may contribute to opioid overdose. OBJECTIVE: To examine the association between PIP and adverse events. DESIGN: Cohort study. PARTICIPANTS: Three million seventy-eight thousand thirty-four individuals age ≥ 18, without disseminated cancer, who received prescription opioids between 2011 and 2015. MAIN MEASURES: We defined PIP as (a) morphine equivalent dose ≥ 100 mg/day in ≥ 3 months; (b) overlapping opioid and benzodiazepine prescriptions in ≥ 3 months; (c) ≥ 4 opioid prescribers in any quarter; (d) ≥ 4 opioid-dispensing pharmacies in any quarter; (e) cash purchase of prescription opioids on ≥ 3 occasions; and (f) receipt of opioids in 3 consecutive months without a documented pain diagnosis. We used Cox proportional hazards models to identify PIP practices associated with non-fatal opioid overdose, fatal opioid overdose, and all-cause mortality, controlling for covariates. KEY RESULTS: All six types of PIP were associated with higher adjusted hazard for all-cause mortality, four of six with non-fatal overdose, and five of six with fatal overdose. Lacking a documented pain diagnosis was associated with non-fatal overdose (adjusted hazard ratio [AHR] 2.21, 95% confidence interval [CI] 2.02-2.41), as was high-dose opioids (AHR 1.68, 95% CI 1.59-1.76). Co-prescription of benzodiazepines was associated with fatal overdose (AHR 4.23, 95% CI 3.85-4.65). High-dose opioids were associated with all-cause mortality (AHR 2.18, 95% CI 2.14-2.23), as was lacking a documented pain diagnosis (AHR 2.05, 95% CI 2.01-2.09). Compared to those who received opioids without PIP, the hazard for fatal opioid overdose with one, two, three, and ≥ four PIP subtypes were 4.24, 7.05, 10.28, and 12.99 (test of linear trend, p < 0.001). CONCLUSIONS: PIP was associated with higher hazard for all-cause mortality, fatal overdose, and non-fatal overdose. Our study implies the possibility of creating a risk score incorporating multiple PIP subtypes, which could be displayed to prescribers in real time. SN - 1525-1497 UR - https://www.unboundmedicine.com/medline/citation/29948815/Potentially_Inappropriate_Opioid_Prescribing_Overdose_and_Mortality_in_Massachusetts_2011_2015_ DB - PRIME DP - Unbound Medicine ER -