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

BackgroundBoth 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.ObjectiveTo examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days.DesignStatewide 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.ParticipantsAll patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients).Main MeasuresDependent 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 ResultsRelative 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.ConclusionsLarge (>= 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.

Automated summary

This study examined the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk in the subsequent 15 days. The results showed that large dose increases and doses >= 60 milligram morphine equivalents (MME) per day were associated with significantly greater 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 and patients prescribed a stable daily dose of 0-29 MME. Patients prescribed benzodiazepines also had significantly greater overdose risk, while being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk.