Shane R Mueller1, Jason M Glanz2, Anh P Nguyen3, Melanie Stowell4, Stephen Koester5, Deborah J Rinehart6, Ingrid A Binswanger7. 1. Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA. Electronic address: Shane.Mueller@kp.org. 2. Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA; Department of Epidemiology, Colorado School of Public Health, 13001 E 17th Place, Mail Stop B-119, Aurora CO 80045, United States. 3. Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA. 4. Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, 777 Bannock St, MC 6551 Denver, Colorado 80204, United States. 5. Anthropology, Health & Behavioral Sciences, University of Colorado Denver, 777 Lawrence St, Denver, CO 80204, United States. 6. Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, 777 Bannock St, MC 6551 Denver, Colorado 80204, United States; Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Aurora CO 80045, United States. 7. Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA; Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Aurora CO 80045, United States; Colorado Permanente Medical Group, 10350 E. Dakota Ave, Denver CO 80247, United States.
Abstract
BACKGROUND: Despite policy efforts to prevent overdose, accidental overdoses among individuals prescribed opioids continue to occur. Guided by Rhodes' Risk Environment Framework, we examined the unintended consequences of restrictive policies by identifying macro policy and micro-level contextual factors that patients prescribed opioids for pain identified as contributing to overdose events. METHODS: Semi-structured interviews were conducted with 31 patients prescribed opioids who experienced an accidental opioid overdose between April 2017 and June 2019 in two health systems. RESULTS: We identified three interrelated factors that emerged within an evolving risk environment and may have increased patients' vulnerability for an accidental opioid overdose: desperation from persistent pain and comorbidities; limited knowledge about opioid medication safety and effectiveness; and restrictive opioid prescribing policies that exacerbated stigma, fear and mistrust and prevented open patient-clinician communication. When experiencing persistent pain, patients took matters into their own hands by taking more medications or in different intervals than prescribed, mixing them with other substances, or using illicitly obtained opioids. CONCLUSION: For some patients, macro-level policies and guidelines designed to reduce opioid overdoses by restricting opioid supply may have paradoxically created a micro-level risk environment that contributed to overdose events in a subset of patients.
BACKGROUND: Despite policy efforts to prevent overdose, accidental overdoses among individuals prescribed opioids continue to occur. Guided by Rhodes' Risk Environment Framework, we examined the unintended consequences of restrictive policies by identifying macro policy and micro-level contextual factors that patients prescribed opioids for pain identified as contributing to overdose events. METHODS: Semi-structured interviews were conducted with 31 patients prescribed opioids who experienced an accidental opioid overdose between April 2017 and June 2019 in two health systems. RESULTS: We identified three interrelated factors that emerged within an evolving risk environment and may have increased patients' vulnerability for an accidental opioid overdose: desperation from persistent pain and comorbidities; limited knowledge about opioid medication safety and effectiveness; and restrictive opioid prescribing policies that exacerbated stigma, fear and mistrust and prevented open patient-clinician communication. When experiencing persistent pain, patients took matters into their own hands by taking more medications or in different intervals than prescribed, mixing them with other substances, or using illicitly obtained opioids. CONCLUSION: For some patients, macro-level policies and guidelines designed to reduce opioid overdoses by restricting opioid supply may have paradoxically created a micro-level risk environment that contributed to overdose events in a subset of patients.
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