Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies

BACKGROUND: Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids. METHODS: We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78–9.04), higher opioid dose (OR 2.57, 95% CI 2.08–3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57–6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35–5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30–3.41), current substance use disorder (OR 2.62, 95% CI 2.09–3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73–2.61), depression (OR 2.22, 95% CI 1.57–3.14), bipolar disorder (OR 2.07, 95% CI 1.77–2.41) or pancreatitis (OR 2.00, 95% CI 1.52–2.64), with absolute risks among patients with the predictor ranging from 2–6 per 1000 for fatal overdose and 4–12 per 1000 for nonfatal overdose. INTERPRETATION: We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/)