Association of Opioid Prescribing Patterns With Prescription Opioid Overdose in Adolescents and Young Adults

Abstract

Importance: Safe opioid prescribing practices are critical to mitigate the risk of prescription opioid overdose in adolescents and young adults. However, studies that examine opioid prescribing patterns associated with prescription opioid overdose have mostly focused on older adults. The generalizability of these studies to adolescents and young adults is unclear.

Objective: To identify opioid prescribing patterns associated with prescription opioid overdose in adolescents and young adults.

Design, setting, and participants: This retrospective cohort study assessed privately insured patients aged 12 to 21 years with opioid prescription claims in the IBM MarketScan Commercial Claims and Encounters database between July 1, 2009, and October 1, 2017, and no cancer diagnosis. Data analysis was performed from January 1 to April 30, 2019.

Main outcomes and measures: The outcome was a treated opioid overdose as indicated by diagnosis codes. On the basis of days supplied, opioid prescription claims were converted to person-days (the unit of analysis) on which opioid exposure would occur if patients took medications as prescribed. Logistic regression with clustered SEs at the patient level was used to model the occurrence of overdose on a person-day as a function of daily opioid dosage category (<30, 30-59, 60-89, 90-119, or ≥120 morphine milligram equivalents), concurrent benzodiazepine use, and extended-release or long-acting opioid use. Regressions controlled for demographic characteristics, year, opioid use within 180 days, and comorbidities (mental health disorder, substance use disorder, and other chronic condition).

Results: A total of 2 752 612 patients (mean [SD] age at cohort entry, 17.2 [2.5] years; 1 451 918 [52.8%] female) participated in the study. Patients had 4 686 355 opioid prescription claims, corresponding to 21 605 444 person-days. Overdose occurred on 255 person-days among 249 patients (0.01% of the sample). Each increase in daily opioid dosage category was associated with higher overdose risk (adjusted odds ratio [AOR], 1.18; 95% CI, 1.05-1.31). Compared with no use, both concurrent benzodiazepine use (AOR, 1.83; 95% CI, 1.24-2.71) and extended-release or long-acting opioid use (AOR, 2.01; 95% CI, 1.16-3.46) were associated with increased overdose risk.

Conclusions and relevance: The findings suggest that when prescribing opioids to adolescents and young adults, practitioners could potentially mitigate overdose risk by using the lowest effective daily dosage, avoiding concurrent opioid and benzodiazepine prescribing, and relying on short-acting opioids. Findings are broadly consistent with prior opioid safety studies focused on older adults.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Chua reported receiving funding from career development award 1K08DA048110-01 from the National Institute on Drug Abuse. Dr Brummett reported working as a consultant for Heron Therapeutics during the conduct of the study and receiving funding from Recro Pharma Inc, the National Institutes of Health, the Michigan Department of Health and Human Services, National Institute on Drug Abuse, and the UM Michigan Genomics Initiative outside the submitted work. In addition, Dr Brummett had a patent to peripheral perineural dexmedetomidine issued and licensed. No other disclosures were reported.

Figures

Figure 1.. Study Design and Sample Inclusion and Exclusion Criteria

Study design for a patient with 2 opioid prescription claims. For a patient with only 1 claim, follow-up terminated at the end of the active period of this claim. Recent opioid use was defined based on the presence of an opioid prescription claim during the 180 days to 1 day before the date of the opioid prescription claim from which person-days derived. Comorbidities were defined based on the presence of diagnosis codes on claims that occurred on the date of each opioid prescription claim or during the 180 days before this date.

Figure 2.. Adjusted Odds Ratios (AORs) of Opioid Overdose for Exposures and Selected Covariates

Daily opioid dosage category was represented by a variable with values of 1 to 5, with 1 corresponding to less than 30, 2 corresponding to 30 to 59, 3 corresponding to 60 to 89, 4 corresponding to 90 to 119, and 5 corresponding to 120 or more morphine milligram equivalents per day. The AOR refers to a 1-unit increase in daily opioid dosage category. The AOR for age in years refers to a 1-year increase in patient age. Boxes represent the point estimate. Horizontal lines represent 95% CIs.