Associations between naloxone prescribing and opioid overdose among patients with acute and chronic pain conditions

Abstract

Aims: To assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose. Design: A retrospective cohort study using data from the Health Facts Database. Setting: Over 600 United States healthcare facilities. Participants: Three patient groups were followed for 2 years during 2009 to 2017: individuals with shoulder or long bone fractures (n = 252 424), chronic pain syndrome (CPS) (n = 76 141), or non-traumatic low back pain (n = 792 956) who received an opioid prescription. Groups were chosen based on previous work. Measurements: The outcome was opioid overdose identified by International Classification of Diseases codes (ICDs) and the primary predictor was number of naloxone prescriptions identified by National Drug Codes (NDCs). Findings: Opioid overdoses occurred among 0.16% of fracture patients (average follow-up time to overdose [AFU] = 240 days), 1.28% of CPS patients (AFU = 244 days), and 0.30% low back pain patients (AFU = 264 days). A total of 58 083 bone fracture patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (hazard ratio [HR] = 1.87, 95% CI = 1.68–2.09), and number of subsequent overdoses (incidence rate ratio [IRR] = 1.89, 95% CI = 1.69–2.12). A total of 19 529 CPS patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.69, 95% CI = 1.61–1.78) and number of subsequent overdoses (IRR = 1.74, 95% CI = 1.67–1.83). A total of 110 608 low back pain patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.33, 95% CI = 1.27–1.40) and number of subsequent overdoses (IRR = 1.35, 95% CI = 1.29–1.41). Conclusions: Receiving a naloxone prescription appears to be associated with increased risk of subsequent opioid overdose among patients with acute and chronic pain, suggesting prescribers often identify patients most in need of naloxone.