Case Review was Associated with Increased Mortality Among Patients Prescribed Opioids with Newly Diagnosed Opioid Use Disorder

In the US, the liberal prescribing of opioids that began in the 1990s led to many harms. In response, policies were implemented to reduce high-risk opioid prescribing. The US Veterans Health Administration (VHA) implemented a clinical decision support tool to assess the risk of serious adverse events among patients prescribed opioids. To evaluate this tool, a previous study randomized facilities to case review the top 1 or 5 percent of high-risk patients identified. This secondary analysis examined the effect of the expansion of case review on individuals with newly diagnosed opioid use disorder (OUD).

• There were 28,251 patients newly diagnosed with OUD during the study period; 19,321 were assigned to the control group and 8930 were assigned to case review.
• All-cause mortality within 90 days for the entire sample was 1.4 percent. In adjusted analyses, the odds of mortality were greater in the case review group (adjusted odds ratio, 1.7), compared with the control group.
• In a post-hoc exploratory analysis, among patients who received an opioid prescription prior to—but not after—OUD diagnosis, the odds of 90-day mortality was 5.9 compared with patients in the control group.

Comments: This is another study suggesting that the US response to the prescription opioid epidemic may be leading to unintended harms. The observed increase in mortality associated with case review could be due a number of factors, including rapid discontinuation or tapering of opioid analgesics, and limited resources to support individuals with newly diagnosed OUD. In any case, this study demonstrates the vulnerability of patients with newly diagnosed OUD, particularly those who are being prescribed opioids.

Darius A. Rastegar, MD

Reference: Auty SG, Barr KD, Frakt AB, et al. Effect of a Veterans Health Administration mandate to case review patients with opioid prescription on mortality among patients with opioid use disorder: a secondary analysis of the STORM randomized control trial. Addiction. 2023;118:870–879.