High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths

TLDR

Overdose deaths in Tennessee rose from 422 to 1,059 per year between 2003 and 2010, with prescription opioids accounting for more deaths than heroin and cocaine combined. The study aimed to evaluate how specific opioid‑prescribing patterns—such as multiple prescribers, pharmacies, and high daily dosages—contribute to overdose risk and to inform targeted risk‑reduction strategies. Researchers conducted a matched case‑control study using Tennessee Controlled Substances Monitoring Program data from 2007 to 2011, selecting overdose cases from death certificates and age‑ and sex‑matched live controls, and defining high‑risk prescribing as ≥4 prescribers or pharmacies per year or a mean daily dosage exceeding 100 MMEs. High‑risk opioid use—defined by ≥4 prescribers, ≥4 pharmacies, or >100 MMEs—was present in 7.6%, 2.5%, and 2.8% of Tennessee patients, respectively, and was associated with adjusted odds ratios of 6.5, 6.0, and 11.2 for overdose death, with 55% of deaths involving at least one risk factor; these findings suggest that targeting such prescribing patterns could reduce opioid‑related mortality.

Abstract

From January 1, 2003, through December 31, 2010, drug overdose deaths in Tennessee increased from 422 to 1059 per year. More of these deaths involved prescription opioids than heroin and cocaine combined.To assess the contribution of certain opioid-prescribing patterns to the risk of overdose death.We performed a matched case-control study that analyzed opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 1, 2007, through December 31, 2011, to identify risk factors associated with opioid-related overdose deaths from January 1, 2009, through December 31, 2010. Case patients were ascertained from death certificate data. Age- and sex-matched controls were randomly selected from among live patients in the TNCSMP.We defined a high-risk number of prescribers or pharmacies as 4 or more per year and high-risk dosage as a daily mean of more than 100 morphine milligram equivalents (MMEs) per year. The main outcome was opioid-related overdose death.From January 1, 2007, through December 31, 2011, one-third of the population of Tennessee filled an opioid prescription each year, and opioid prescription rates increased from 108.3 to 142.5 per 100 population per year. Among all patients in Tennessee prescribed opioids during 2011, 7.6% used more than 4 prescribers, 2.5% used more than 4 pharmacies, and 2.8% had a mean daily dosage greater than 100 MMEs. Increased risk of opioid-related overdose death was associated with 4 or more prescribers (adjusted odds ratio [aOR], 6.5; 95% CI, 5.1-8.5), 4 or more pharmacies (aOR, 6.0; 95% CI, 4.4-8.3), and more than 100 MMEs (aOR, 11.2; 95% CI, 8.3-15.1). Persons with 1 or more risk factor accounted for 55% of all overdose deaths.High-risk use of prescription opioids is frequent and increasing in Tennessee and is associated with increased overdose mortality. Use of prescription drug–monitoring program data to direct risk-reduction measures to the types of patients overrepresented among overdose deaths might reduce mortality associated with opioid abuse.