Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid Patients

Med Care. 2017 Jul;55(7):661-668. doi: 10.1097/MLR.0000000000000738.


Background: The Centers for Disease Control and Prevention recognizes Medicaid as a high-risk population for fatal opioid overdose. Further research is needed to identify factors that put Medicaid patients at increased risk.

Objective: To determine whether patterns of opioid use are associated with risk of opioid-related mortality among opioid users.

Design: This is a retrospective cohort study.

Patients: In total, 150,821 noncancer pain patients aged 18-64 years with ≥1 opioid prescription, April 2006 to December 2010, Washington Medicaid.

Measures: Average daily dose (morphine equivalents), opioid schedule/duration of action, sedative-hypnotic use.

Results: Compared with patients at 1-19 mg/d, risk of opioid overdose death significantly increased at 50-89 mg/d [adjusted hazard ratio (aHR), 2.3; 95% confidence interval (CI), 1.4-4.1], 90-119 mg/d (aHR, 4.0; 95% CI, 2.2-7.3), 120-199 mg/d (aHR, 3.8; 95% CI, 2.1-6.9), and ≥200 mg/d (aHR, 4.9; 95% CI, 2.9-8.1). Patients using long-acting plus short-acting Schedule II opioids had 4.7 times the risk of opioid overdose death than non-Schedule II opioids alone (aHR, 4.7; 95% CI, 3.3-6.9). Sedative-hypnotic use compared with nonuse was associated with 6.4 times the risk of opioid overdose death (aHR, 6.4; 95% CI, 5.0-8.4). Risk was particularly high for opioids combined with benzodiazepines and skeletal muscle relaxants (aHR, 12.6; 95% CI, 8.9-17.9). Even at opioid doses 1-19 mg/d, patients using sedative-hypnotics concurrently had 5.6 times the risk than patients without sedative-hypnotics (aHR, 5.6; 95% CI, 1.6-19.3).

Conclusions: Our findings support Federal guideline-recommended dosing thresholds in opioid prescribing. Concurrent sedative-hypnotic use even at low opioid doses poses substantially greater risk of opioid overdose.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Analgesics, Opioid / administration & dosage*
  • Analgesics, Opioid / poisoning*
  • Chronic Pain / drug therapy
  • Drug Overdose / mortality*
  • Female
  • Humans
  • Male
  • Medicaid*
  • Middle Aged
  • Retrospective Studies
  • Risk Assessment
  • United States / epidemiology
  • Young Adult


  • Analgesics, Opioid