Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy

Abstract

<div class="section"> <a class="named-anchor" id="d449169e242"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e243">Background</h5> <p id="Par1">Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking. </p> </div><div class="section"> <a class="named-anchor" id="d449169e247"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e248">Objective</h5> <p id="Par2">To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone. </p> </div><div class="section"> <a class="named-anchor" id="d449169e252"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e253">Design</h5> <p id="Par3">Retrospective cohort.</p> </div><div class="section"> <a class="named-anchor" id="d449169e257"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e258">Setting</h5> <p id="Par4">Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado. </p> </div><div class="section"> <a class="named-anchor" id="d449169e262"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e263">Participants</h5> <p id="Par5">We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients. </p> </div><div class="section"> <a class="named-anchor" id="d449169e267"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e268">Main Measures</h5> <p id="Par6">Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed. </p> </div><div class="section"> <a class="named-anchor" id="d449169e272"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e273">Key Results</h5> <p id="Par7">A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic = 0.73, 95% confidence interval [CI] 0.69–0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic = 0.75, 95% CI 0.70–0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively. </p> </div><div class="section"> <a class="named-anchor" id="d449169e277"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e278">Conclusions</h5> <p id="Par9">Among patients on chronic opioid therapy, the predictive model identified 66–82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site. </p> </div><div class="section"> <a class="named-anchor" id="d449169e282"> <!-- named anchor --> </a> <h5 class="section-title" id="d449169e283">Electronic supplementary material</h5> <p id="d449169e285">The online version of this article (10.1007/s11606-017-4288-3) contains supplementary material, which is available to authorized users. </p> </div>