Morphine Equivalent Total Dosage as Predictor of Adverse Outcomes in Opioid Prescribing.

OBJECTIVE: The objective of this work was to develop a risk prediction model for opioid overdose and opioid use disorder for patients at first opioid prescription and compare the predictive accuracy of morphine equivalent total dosage with the predictive accuracy of daily dosage . DESIGN: Records from patients 18-79 years of age with opioid prescriptions between January 1, 2016, and June 30, 2019, no prior history of adverse outcomes, and no malignant cancer diagnoses were collected from the electronic health record system of a medium-sized central Ohio health care system (n = 219,276). A Cox proportional-hazards model was developed to predict the adverse outcomes of opioid overdose and opioid use disorder from patient sociodemographic, pharmacological, and clinical diagnosis factors. RESULTS: During the study time frame, 573 patients experienced overdoses, and 2,571 patients were diagnosed with opioid use disorder. Morphine equivalent total dosage of opioid prescriptions was identified as a stronger predictor of adverse outcomes (C = 0.797) than morphine equivalent daily dosage (C = 0.792), with the best predictions coming from a model that includes both predictors (C = 0.803). In the model with both daily and total dosage predictors, patients receiving a high total / low daily dosage experienced a higher risk (hazard ratio [HR] = 2.17) than those receiving a low total / high daily dosage (HR = 2.02). Those receiving a high total / high daily dosage experienced the greatest risk of all (HR = 3.09). CONCLUSIONS: These findings demonstrate the value of including morphine equivalent total dosage as a predictor of adverse opioid outcomes and suggest that total dosage may be more strongly correlated with increased risk than daily dosage.

Clinical care for opioid-using pregnant and postpartum women: the role of obstetric providers.

We review clinical care issues that are related to illicit and therapeutic opioid use among pregnant women and women in the postpartum period and outline the major responsibilities of obstetrics providers who care for these patients during the antepartum, intrapartum, and postpartum periods. Selected patient treatment issues are highlighted, and case examples are provided. Securing a strong rapport and trust with these patients is crucial for success in delivering high-quality obstetric care and in coordinating services with other specialists as needed. Obstetrics providers have an ethical obligation to screen, assess, and provide brief interventions and referral to specialized treatment for patients with drug use disorders. Opioid-dependent pregnant women often can be treated effectively with methadone or buprenorphine. These medications are classified as pregnancy category C medications by the Food and Drug Administration, and their use in the treatment of opioid-dependent pregnant patients should not be considered "off-label." Except in rare special circumstances, medication-assisted withdrawal during pregnancy should be discouraged because of a high relapse rate. Acute pain management in this population deserves special consideration because patients who use opioids can be hypersensitive to pain and because the use of mixed opioid-agonist/antagonists can precipitate opioid withdrawal. In the absence of other indications, pregnant women who use opioids do not require more intense medical care than other pregnant patients to ensure adequate treatment and the best possible outcomes. Together with specialists in pain and addiction medicine, obstetricians can coordinate comprehensive care for pregnant women who use opioids and women who use opioids in the postpartum period.