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Journal of General Internal Medicine
Published in: Journal of General Internal Medicine 3/2024

Open Access 04-10-2023 | Opioids | Original Research

Impact of 30-day prescribed opioid dose trajectory on fatal overdose risk: A population-based, statewide cohort study

Authors: Stephen G. Henry, MD MSc, Shao-You Fang, PhD, Andrew J. Crawford, PhD, Garen J. Wintemute, MD MPH, Iraklis Erik Tseregounis, PhD, James J. Gasper, PharmD BCPP, Aaron Shev, PhD, Abigail R. Cartus, PhD MPH, Brandon D.L. Marshall, PhD, Daniel J. Tancredi, PhD, Magdalena Cerdá, DrPH, Susan L. Stewart, PhD

Published in: Journal of General Internal Medicine | Issue 3/2024

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Abstract

Background

Both increases and decreases in patients’ prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined.

Objective

To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days.

Design

Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors.

Participants

All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients).

Main Measures

Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME).

Key Results

Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk.

Conclusions

Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.
Appendix
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Metadata
Title
Impact of 30-day prescribed opioid dose trajectory on fatal overdose risk: A population-based, statewide cohort study
Authors
Stephen G. Henry, MD MSc
Shao-You Fang, PhD
Andrew J. Crawford, PhD
Garen J. Wintemute, MD MPH
Iraklis Erik Tseregounis, PhD
James J. Gasper, PharmD BCPP
Aaron Shev, PhD
Abigail R. Cartus, PhD MPH
Brandon D.L. Marshall, PhD
Daniel J. Tancredi, PhD
Magdalena Cerdá, DrPH
Susan L. Stewart, PhD
Publication date
04-10-2023
Publisher
Springer International Publishing
Published in
Journal of General Internal Medicine / Issue 3/2024
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI
https://doi.org/10.1007/s11606-023-08419-6

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