Opioid prescriptions have fallen in recent years, after health care providers became more aware of the risks of overdoses and the federal government tightened prescribing rules. While opioids were dispensed at a rate of 81 prescriptions for every 100 Americans in 2012, that rate dropped nearly in half by 2020, according to data from the U.S. Centers for Disease Control and Prevention. However, overdoses involving prescription opioids have remained high. In 2020, more than 68,000 overdose deaths in the U.S. involved an illicit or prescription opioid, up from about 21,000 in 2010, according to federal data.
Researchers are trying to predict who is most at risk for having an opioid overdose—and they’re finding that some Americans face more danger than others. A new study published in JAMA Network Open has found that a person’s age, sex, race, insurance type, and more can all place them at greater risk.
In the JAMA study, researchers looked at data for nearly 237,000 adults in Oregon who didn’t have a previous history of using opiates but who were prescribed them in 2015. They tracked the data for an additional three years and found that 667 people had fatal or non-fatal opioid overdoses during that time: a rate of about 3 in 1,000. This is a relatively high rate for a population without a prior history of opiate use, says Dr. Scott Weiner, study co-author and an associate professor of emergency medicine Harvard Medical School. “Just getting an opiate prescription is going to put you at risk for having an overdose.”
Weiner and his team teased out several risk factors that seemed to put certain Oregon patients at higher risk for an overdose. Men, who are more likely than women to overdose on any kind of drug, were 29% more likely to overdose than women in this group; residents of metropolitan counties were 51% more likely to overdose than people who didn’t live in cities, and Black patients were 55% more likely to overdose than white patients. (However, the authors note that since nearly 87% of Oregon residents are white, this may not be representative of the whole country.)
Being elderly seems to put people at an especially heightened risk. People ages 75 and older were about three times more likely to overdose than people ages 35 to 44. This is particularly worrisome because older adults are more vulnerable to overdose in several ways; they have a weaker ability to metabolize opiates than younger people, for one.
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Using certain types of insurance was also linked to a greater likelihood of overdose. Patients with Medicaid or Medicare Advantage—an insurance plan offered by some private companies that serves as a replacement for Medicare—were more likely to overdose than people with commercial insurance. People who qualified for both Medicaid and Medicare Advantage were especially vulnerable, facing more than four times the risk of overdosing as people with commercial insurance. The type of insurance a person uses can signal whether they’re facing other risks—including food, housing, and job insecurity—which other research has shown also puts people at greater risk for overdose, Weiner says. “Social factors really do play a part in this as well,” he says.
However, even people who are at higher risk of overdosing should not lose access to opioids when they have severe pain, Weiner says. Although opioid prescriptions are widespread in the U.S, some demographics have historically had inadequate access to them, including Black patients. In part, experts attribute this discrepancy to racism and bias among prescribers; health care providers have been shown to underestimate Black patients’ pain. What the new research instead suggests, Weiner says, is that both patients and prescribers should take steps to make sure they’re approaching opiates with caution, especially if patients have risk factors placing them at greater risk of an overdose.
Health care providers can help reduce risk by taking certain precautions, Weiner says. One is to prescribe non-opioid medications whenever possible (or tell patients to use them once their pain subsides) and make sure that patients are educated about how to use opioids and dispose of them safely. When a patient has one or more risk factors—like those Weiner and his team identified—providers should consider spending more appointment time with them to make sure they know how to use the medication safely, or call them to check in following their visit, Weiner says. Providers can also use several tools in order to dispense these drugs more judiciously, including checking their states’ prescription drug monitoring programs to see patients’ prescription histories, and prescribing the smallest dosage possible that will adequately treat a person’s pain.
Patients and their loved ones can help reduce overdose risk, too. Patients and their families should recognize that opioids are only meant to help with the worst pain and should be disposed of safely, like at a pharmacy, Weiner says. Families should also monitor the person taking opioids for signs of tolerance, dependence, or opioid use disorder—such as a patient refilling their prescription early, or using the drug differently than they were prescribed, says Weiner. If that happens, they should reach out to a prescriber to ask for help. “If they do fall into the higher risk factors, then that’s good for them to know,” says Weiner. “Because when they do get a prescription, they should be asking the prescriber how they can be safe with it.”