“In recent decades, the medical community has become acutely aware of the dangers posed by prescription opioids and their contribution to the opioid epidemic,” explains David R. Foster, PharmD, FCCP. “We’ve made great strides in recognizing the need for caution in prescribing opioids, but we are still lacking evidence-based practices that can be applied at the individual patient level, particularly to help identify patient characteristics and opioid prescribing practices that can inform safe opioid prescribing.”

For a paper published in the Journal of the American Pharmacists Association, Dr. Foster and colleagues sought to identify factors associated with adverse health outcomes and healthcare utilization using a statewide health information exchange. “We hypothesized that patients receiving higher dosages of opioids, taking them for long durations, and using them concurrently with other central nervous system medications were at higher risk for the composite outcome (abuse, dependence, and overdose) and mortality and would, therefore, use more healthcare resources,” Dr. Foster says.

Poorer Outcomes & Increased Healthcare Utilization

The researchers conducted a retrospective cohort study using data on adult, opioid-naïve patients who received an opioid prescription between January 2012 and December 2017 in the Indiana Network for Patient Care. “This represented more than 1.3 million opioid prescriptions and about 340,000 patients,” says Dr. Foster. “Opioid prescription details and patient characteristics were collected to identify factors associated with poor outcomes and healthcare utilization.”

The study team’s findings, according to Dr. Foster, are largely in agreement with similar studies, particularly in regard to a number of patient characteristics and opioid prescribing practices that are associated with poor outcomes and increased healthcare utilization. “We found that many factors were associated with poor outcomes, including higher opioid dosages, larger opioid supply, concurrent use of short- and long-acting opioids, and overlapping prescriptions of opioids with benzodiazepines or gabapentin/pregabalin,” Dr. Foster adds. “Many of these same factors were also associated with increased healthcare utilization, including both hospitalizations and emergency department visits.”

The study used the composite outcome of opioid abuse, dependence, and/or overdose as it was thought to reflect problematic opioid use and, therefore, may share some of the same risk factors that predict opioid abuse disorder, Dr. Foster notes. “Many factors were associated with both the composite outcome and mortality,” he says (Table), “including patient factors, such as older age, presence of comorbidities, and mental health conditions, and opioid prescribing factors, such as larger opioid quantities, use of both short- and long-acting opioids, and the use of benzodiazepines and/or gapapentenoids. However, some factors, for example, larger opioid dosages and long-term use, were associated with the composite outcome but not mortality.”

The Balance Between Safety & Efficacy

Dr. Foster and colleagues note that their findings reinforce what existing literature and recent guidelines suggest—that clinicians and pharmacists should exercise caution when prescribing and dispensing opioids. “This includes using the lowest possible dose, prescribing limited durations, avoiding combining short- and long-acting opioids, and avoiding concurrent therapy with other central nervous system medications,” he says. “Likewise, caution should be exercised in older patients and in patients with comorbidities, particularly mental health conditions.”

The study team would like to see future research on opioid prescribing focused on validation of models and tools that can help predict the risk of adverse outcomes at the individual patient level, ideally at the time of prescribing and dispensing. “I think this is the next logical step in this research,” Dr. Foster adds. “Opioids continue to play an important role in pain management. We have steadily developed an understanding and appreciation of certain factors that increase the risk of opioid harms; the challenge is finding the right balance between safety and efficacy.”