Prescription Opioid Dispensing Patterns Prior to Heroin Overdose in a State Medicaid Program: a Case-Control Study
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College of Pharmacy, Oregon State University, Portland, OR, USA; 2Comagine Health, Portland, OR, USA; 3University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA; 4Oregon Health & Science University, Portland, OR, USA.
BACKGROUND: A large proportion of individuals who use heroin report initiating opioid use with prescription opioids. However, patterns of prescription opioid use preceding heroin-related overdose have not been described. OBJECTIVE: To describe prescription opioid use in the year preceding heroin overdose. DESIGN: Case-control study comparing prescription opioid use with a heroin-involved overdose, non-heroininvolved opioid overdose, and non-overdose controls from 2015 to 2017. PARTICIPANTS: Oregon Medicaid beneficiaries with linked administrative claims, vital statistics, and prescription drug monitoring program data. MAIN MEASURES: Opioid, benzodiazepine, and other central nervous system depressant prescriptions preceding overdose; among individuals with one or more opioid prescription, we assessed morphine milligram equivalents per day, overlapping prescriptions, prescriptions from multiple prescribers, long-term use, and discontinuation of long-term use. KEY RESULTS: We identified 1458 heroin-involved overdoses (191 fatal) and 2050 non-heroin-involved opioid overdoses (266 fatal). In the 365 days prior to their overdose, 45% of individuals with a heroin-involved overdose received at least one prescribed opioid compared with 78% of individuals who experienced a non-heroininvolved opioid overdose (p < 0.001). For both heroinand non-heroin-involved overdose cases, the likelihood of receiving an opioid increased with age. Among heroin overdose cases with an opioid dispensed, the rate of multiple pharmacy use was the only high-risk opioid pattern that was greater than non-overdose controls (adjusted odds ratio 3.2; 95% confidence interval 1.48 to 6.95). Discontinuation of long-term opioid use was not common prior to heroin overdose and not higher than discontinuation rates among non-overdose controls.
Prior Presentations Prescription Drug Abuse and Heroin Summit in Atlanta, GA, April 22–24, 2019. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-020-06192-4) contains supplementary material, which is available to authorized users. Received December 5, 2019 Accepted August 27, 2020
CONCLUSIONS: Although individuals with a heroininvolved overdose were less likely to receive prescribed opioids in the year preceding their overdose relative to non-heroin opioid overdose cases, prescription opioid use was relatively common and increased with age. Discontinuation of long-term prescription opioid use was not associated with heroin-involved overdose. KEY WORDS: prescription opioids; heroin; overdose. J Gen Intern Med DOI: 10.1007/s11606-020-06192-4 © Society of General Internal Medicine 2020
INTRODUCTION
The opioid epidemic has evolved over the last decade, shifting from being primarily related to prescription opioids (natural or semi-synthetic opio
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