Associations between naloxone prescribing and opioid overdose among patients with acute and chronic pain conditions

Abstract

AimsTo assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose. Design A retrospective cohort study using data from the Health Facts Database. Setting Over 600 United States healthcare facilities. Participants Three patient groups were followed for 2 years during 2009 to 2017: individuals with shoulder or long bone fractures (n = 252 424), chronic pain syndrome (CPS) (n = 76 141), or non-traumatic low back pain (n = 792 956) who received an opioid prescription. Groups were chosen based on previous work. MeasurementsThe outcome was opioid overdose identified by International Classification of Diseases codes (ICDs) and the primary predictor was number of naloxone prescriptions identified by National Drug Codes (NDCs).Findings Opioid overdoses occurred among 0.16% of fracture patients (average follow-up time to overdose[AFU] = 240 days), 1.28% of CPS patients (AFU = 244 days), and 0.30% low back pain patients (AFU = 264 days). A total of 58 083 bone fracture patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (hazard ratio [HR] = 1.87, 95% CI = 1.68-2.09), and number of subsequent overdoses (incidence rate ratio [IRR] = 1.89, 95% CI = 1.69-2.12). A total of 19 529 CPS patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.69, 95% CI = 1.61-1.78) and number of subsequent overdoses (IRR = 1.74, 95% CI = 1.67-1.83). A total of 110 608 low back pain patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.33, 95% CI = 1.27-1.40) and number of subsequent overdoses (IRR = 1.35, 95% CI = 1.29-1.41). Conclusions Receiving a naloxone prescription appears to be associated with increased risk of subsequent opioid overdose among patients with acute and chronic pain, suggesting prescribers often identify patients most in need of naloxone.

Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies

“…Twenty-four studies were conducted in the United States, 3 were conducted in Canada and 1 was conducted in the United Kingdom. Twenty-one studies 23 , 24 , 40 – 47 , 50 – 53 , 55 – 57 , 59 – 62 included only patients with chronic noncancer pain, and 7 27 , 28 , 39 , 48 , 49 , 54 , 58 included patients with either chronic noncancer or cancer-related pain. Twenty-two studies enrolled patients with previous or current substance use disorder (median proportion 9%, IQR 4%–13%), 23 , 24 , 27 , 28 , 39 – 43 , 46 , 48 – 51 , 53 – 55 , 57 , 58 , 60 – 62 and 3 studies excluded patients with comorbid substance use disorder.…”

“…Twenty-one studies 23 , 24 , 40 – 47 , 50 – 53 , 55 – 57 , 59 – 62 included only patients with chronic noncancer pain, and 7 27 , 28 , 39 , 48 , 49 , 54 , 58 included patients with either chronic noncancer or cancer-related pain. Twenty-two studies enrolled patients with previous or current substance use disorder (median proportion 9%, IQR 4%–13%), 23 , 24 , 27 , 28 , 39 – 43 , 46 , 48 – 51 , 53 – 55 , 57 , 58 , 60 – 62 and 3 studies excluded patients with comorbid substance use disorder. 45 , 52 , 56 Twenty-three studies included patients with comorbid mental illness (median proportion 31%, IQR 20%–41%), 23 , 24 , 27 , 28 , 40 – 42 , 45 – 49 , 51 – 58 , 60 – 62 and 5 studies exclusively recruited veterans.…”

“… 23 , 27 , 40 , 41 , 43 , 45 , 48 , 49 , 52 , 54 – 57 , 61 , 62 , 67 § In 22 studies. 23 , 24 , 27 , 28 , 39 – 43 , 46 , 48 – 51 , 53 – 55 , 57 , 58 , 60 – 62 Three studies explicitly excluded patients with comorbid substance use disorders. 45 , 52 , 56 ¶ In 23 studies.…”

“… 23 , 24 , 27 , 28 , 40 – 42 , 45 – 49 , 51 – 58 , 60 – 62 ** Ten studies reported a small proportion of patients with acute pain (2%–12%) 27 , 28 , 41 , 44 , 45 , 52 , 54 , 60 or conditions that may not present with chronic pain (13%–17%) 46 , 49 †† In 22 studies. 23 , 24 , 40 – 47 , 50 – 53 , 55 – 62 One study reported regression models for chronic noncancer pain and cancer pain separately. 58 ‡‡ In 1 study.…”

“… †† In 22 studies. 23 , 24 , 40 – 47 , 50 – 53 , 55 – 62 One study reported regression models for chronic noncancer pain and cancer pain separately. 58 …”