November 9, 2018 Rising rates and doses of prescription opioids may be a warning sign of an increased risk of death even for patients not recognized as having opioid use disorder (OUD), reports a study in the Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine (ASAM). The journal is published in the Lippincott portfolio by Wolters Kluwer.
Information on opioid prescribing trends drawn from state Prescription Drug Monitoring Programs (PDMPs) might help in identifying people at high risk of overdose, suggests the report by Yih-Ing Hser, PhD, of University of California Los Angeles and colleagues. They write, "The PDMPs offer important resources useful for monitoring physician and patient behaviors to determine potentially unsafe prescription and usage patterns."
Prescribing Data Identifies Patients at High Risk of Death With or Without Opioid Use Disorder
The current study focused on 2,576 adults with OUD diagnosed in a Los Angeles healthcare system. In an earlier study published in Journal of Addiction Medicine last year, 18 percent of patients in a general healthcare system diagnosed with OUD died within four years. In that group of patients, mortality risk was more than 10 times higher than in the general population, adjusted for age and sex.
In the new study, Dr. Hser and colleagues used California PDMP data to analyze trends in opioid prescribing for patients with OUD, compared to a group of 5,152 patients without OUD. The goal was to assess whether patterns in opioid prescribing over time predicted the risk of death in patients with or without OUD. The two groups were matched in terms of age, sex, and physical and mental health conditions (comorbidity). The four-year mortality rate in the non-OUD group was about ten percent.
The PDMP data confirmed that patients with OUD received more opioid prescriptions and higher opioid doses than patients without OUD. Higher levels of opioid prescribing were associated with greater mortality risk. Although this relationship was stronger in the patients with OUD, it was also present in the non-OUD group.
Average daily opioid doses (expressed in "morphine milligram equivalents" (MMEs) were about 87 MMEs in patients with OUD who died versus 52 MMEs in patients with OUD who did not die. In the non-OUD control group, average doses were about 20 MMEs in patients who died versus 9 MMEs in those who did not die.
Patients with OUD who died had the sharpest increase in opioid dose over time: about 8 grams per year higher than in patients without OUD who survived. "Providers treating patients with OUD need to be alerted to escalating opioid prescribing patterns in light of the finding that the deceased OUD patients demonstrated the sharpest escalation of number of opioid prescriptions and total dosage," Dr. Hser and coauthors write.
The number and dose of opioid prescriptions were higher for older patients, patients on public health insurance, those with cancer, and those with chronic pain. Cancer accounted for about 17 percent of deaths in both groups, but overdose deaths were much more frequent among patients with OUD: about 17 percent, compared to three percent in patients without an OUD diagnosis.
State PDMPs are viewed as an important resource for identifying patients at risk for misuse, overdose, addiction and other consequences of prescription medication misuse. A key strength of these databases is that they include information on opioids from multiple prescribers. A limitation is that they do not provide information on other potential sources of prescription and non-prescription opioids (such as illicitly obtained opioids or heroin).
Dr. Hser and colleagues conclude: "In addition to high levels of opioid prescriptions, clinicians need to pay special attention to escalating patterns of prescription dosage, which can be a critical warning signal for heightened mortality risks, particularly among OUD patients."
About Journal of Addiction Medicine
The mission of Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine, is to promote excellence in the practice of addiction medicine and in clinical research as well as to support addiction medicine as a mainstream medical specialty. Published six times a year, the Journal is designed for all physicians and other mental health professionals who need to keep up-to-date with the treatment of addiction. Under the guidance of an esteemed Editorial Board, peer-reviewed articles published in the Journal focus on developments in addiction medicine as well as on treatment innovations and ethical, economic, forensic, and social topics. Visit us on the web at www.JournalAddictionMedicine.com .
About The American Society of Addiction Medicine
The American Society of Addiction Medicine (ASAM)Â is a professional society representing more than 6000 physicians, clinicians, and associated professionals in the field of addiction medicine. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addiction. Visit us on the web at www.ASAM.org; follow @ASAMorg on Twitter.