First Opioid Prescription and Subsequent High-Risk Opioid Use: a National Study of Privately Insured and Medicare Advantage Adults

Abstract

Background: National guidelines make recommendations regarding the initial opioid prescriptions, but most of the supporting evidence is from the initial episode of care, not the first prescription.

Objective: To examine associations between features of the first opioid prescription and high-risk opioid use in the 18 months following the first prescription.

Design: Retrospective cohort study using data from a large commercial insurance claims database for 2011-2014 to identify individuals with no recent use of opioids and follow them for 18 months after the first opioid prescription.

Participants: Privately insured patients aged 18-64 and Medicare Advantage patients aged 65 or older who filled a first opioid prescription between 07/01/2011 and 06/30/2013.

Main outcomes and measures: High-risk opioid use was measured by having (1) opioid prescriptions overlapping for 7 days or more, (2) opioid and benzodiazepine prescriptions overlapping for 7 days or more, (3) three or more prescribers of opioids, and (4) a daily dosage exceeding 120 morphine milligram equivalents, in each of the six quarters following the first prescription.

Key results: All three features of the first prescription were strongly associated with high-risk use. For example, among privately insured patients, receiving a long- (vs. short-) acting first opioid was associated with a 16.9-percentage-point increase (95% CI, 14.3-19.5), a daily MME of 50 or more (vs. less than 30) was associated with a 12.5-percentage-point increase (95% CI, 12.1-12.9), and a supply exceeding 7 days (vs. 3 or fewer days) was associated with a 4.8-percentage-point increase (95% CI, 4.5-5.2), in the probability of having a daily dosage of 120 MMEs or more in the long term, compared to a sample mean of 4.2%. Results for the Medicare Advantage patients were similar.

Conclusions: Long-acting formulation, high daily dosage, and longer duration of the first opioid prescription were each associated with increased high-risk use of opioids in the long term.

Keywords: health services research; pain; physician behavior; prescription drug abuse.

Fig. 1

Predicted probability of overlapping opioid prescriptions by features of the first opioid prescription, privately insured patients 18–64 years of age. Notes: significance denotes the difference between reference category and other categories; MME, morphine milligram equivalent; ref., reference group; ***p < 0.001; **p < 0.01; *p < 0.05.

Fig. 2

Predicted probability of overlapping opioids and benzodiazepines by features of the first opioid prescription, privately insured patients 18–64 years of age. Notes: significance denotes the difference between reference category and other categories; MME – morphine milligram equivalent; ref., reference group; ***p < 0.001; **p < 0.01; *p < 0.05.

Fig. 3

Predicted probability of three or more prescribers of opioids by features of the first opioid prescription, privately insured patients 18–64 years of age. Notes: significance denotes the difference between reference category and other categories; MME, morphine milligram equivalent; ref., reference group; ***p < 0.001; **p < 0.01; *p < 0.05.

Fig. 4

Predicted probability of 120 or more daily average MMEs by features of the first opioid prescription, privately insured patients 18–64 years of age. Notes: significance denotes the difference between reference category and other categories; MME, morphine milligram equivalent; ref., reference group; ***p < 0.001; **p < 0.01; *p < 0.05.