{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T13:03:16Z","timestamp":1783602196756,"version":"3.55.0"},"reference-count":39,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2021,12,8]],"date-time":"2021-12-08T00:00:00Z","timestamp":1638921600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Emergent BioSolutions (United States)","award":["Unrestricted"],"award-info":[{"award-number":["Unrestricted"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pharmaceuticals"],"abstract":"<jats:p>While current opioid prescribing guidelines highlight a dose-response relationship between therapeutic management and overdose risk, other concurrent risk factors have also been identified. However, there is little data in assessing the relationship between risk factor prevalence, associated provider communication, and subsequent perceptions of overdose risk among chronic pain, opioid-managed (CPOM) patients. An online questionnaire was distributed in June 2020 to a sample of CPOM individuals (n = 190) treated with an opioid prescription at or above 50 daily MME, or any dosage alongside benzodiazepines. CPOM individuals reported a mean daily MME of 470, with half (52.6%) receiving a concurrent benzodiazepine prescription. All patients reported past month alcohol use, and 67.4% indicated a risk-elevating diagnosed medical condition. In assessing provider communication, 41.6% reported no discussion focusing on the risks of one\u2019s opioid therapy. Subsequently, 62.1% perceived themselves as having \u201cno risk\u201d, and 60.0% were \u201cnot at all concerned\u201d (60.0%) about experiencing an opioid overdose. Organizational policies should focus on implementing consistent methods of patient education regarding overdose risk, as well as assessments of behaviors or characteristics that my increase an individual\u2019s risk of opioid overdose. These policies should also include other forms of evidence-based overdose risk prevention such as co-prescriptions of naloxone.<\/jats:p>","DOI":"10.3390\/ph14121279","type":"journal-article","created":{"date-parts":[[2021,12,8]],"date-time":"2021-12-08T23:30:00Z","timestamp":1639006200000},"page":"1279","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Opioid Dosage Levels, Concurrent Risk Factors and Self-Perceptions among Chronic Pain, Opioid-Managed Individuals at Elevated Risk for Opioid Overdose"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3753-9651","authenticated-orcid":false,"given":"Matthew S.","family":"Ellis","sequence":"first","affiliation":[{"name":"Department of Psychiatry, Campus Box 8134, St. Louis School of Medicine, Washington University in St. Louis, 660 S. Euclid Ave., St. Louis, MO 63110, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zachary A.","family":"Kasper","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, Campus Box 8134, St. Louis School of Medicine, Washington University in St. Louis, 660 S. Euclid Ave., St. Louis, MO 63110, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Gold","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, Campus Box 8134, St. Louis School of Medicine, Washington University in St. Louis, 660 S. Euclid Ave., St. Louis, MO 63110, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Theodore J.","family":"Cicero","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, Campus Box 8134, St. Louis School of Medicine, Washington University in St. Louis, 660 S. Euclid Ave., St. Louis, MO 63110, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,12,8]]},"reference":[{"key":"ref_1","unstructured":"Centers for Disease Control and Prevention (2021, October 31). Drug Overdose Deaths in the U.S. up 30% in 2020, Available online: https:\/\/www.cdc.gov\/nchs\/pressroom\/nchs_press_releases\/2021\/20210714.htm."},{"key":"ref_2","unstructured":"Centers for Disease Control and Prevention (2021, October 31). Prescription Opioid Overdose Death Maps, Available online: https:\/\/www.cdc.gov\/drugoverdose\/deaths\/prescription\/maps.html."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1624","DOI":"10.1001\/jama.2016.1464","article-title":"CDC Guideline for Prescribing Opioids for Chronic Pain\u2014United States, 2016","volume":"315","author":"Dowell","year":"2016","journal-title":"JAMA"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"295","DOI":"10.7326\/M14-2775","article-title":"National Institutes of Health Pathways to Prevention Workshop: The role of opioids in the treatment of chronic pain","volume":"162","author":"Reuben","year":"2015","journal-title":"Ann. Intern. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"367","DOI":"10.7326\/M18-1243","article-title":"Opioid Prescribing in the United States Before and after the Centers for Disease Control and Prevention\u2019s 2016 Opioid Guideline","volume":"169","author":"Bohnert","year":"2018","journal-title":"Ann. Intern. Med."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Encinosa, W., Bernard, D., and Selden, T.M. (2021). Opioid and non-opioid analgesic prescribing before and after the CDC\u2019s 2016 opioid guideline. Int. J. Health Econ. Manag., 1\u201352.","DOI":"10.1007\/s10754-021-09307-4"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e2116860","DOI":"10.1001\/jamanetworkopen.2021.16860","article-title":"Changes in Initial Opioid Prescribing Practices After the 2016 Release of the CDC Guideline for Prescribing Opioids for Chronic Pain","volume":"4","author":"Goldstick","year":"2021","journal-title":"JAMA Netw. Open"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e2111826","DOI":"10.1001\/jamanetworkopen.2021.11826","article-title":"Association of the 2016 US Centers for Disease Control and Prevention Opioid Prescribing Guideline With Changes in Opioid Dispensing After Surgery","volume":"4","author":"Sutherland","year":"2021","journal-title":"JAMA Netw. Open"},{"key":"ref_9","unstructured":"Centers for Disease Control and Prevention (2021, October 21). U.S. Opioid Dispensing Rate Maps, Available online: https:\/\/www.cdc.gov\/drugoverdose\/rxrate-maps\/index.html."},{"key":"ref_10","unstructured":"Rockville, M.D. (2020). Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55)."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1001\/archinternmed.2011.117","article-title":"Opioid dose and drug-related mortality in patients with nonmalignant pain","volume":"171","author":"Gomes","year":"2011","journal-title":"Arch. Intern. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"85","DOI":"10.7326\/0003-4819-152-2-201001190-00006","article-title":"Opioid prescriptions for chronic pain and overdose: A cohort study","volume":"152","author":"Dunn","year":"2010","journal-title":"Ann. Intern. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1315","DOI":"10.1001\/jama.2011.370","article-title":"Association between opioid prescribing patterns and opioid overdose-related deaths","volume":"305","author":"Bohnert","year":"2011","journal-title":"JAMA"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"637","DOI":"10.1002\/cpt.2027","article-title":"Tolerance to Opioid-Induced Respiratory Depression in Chronic High-Dose Opioid Users: A Model-Based Comparison With Opioid-Naive Individuals","volume":"109","author":"Algera","year":"2021","journal-title":"Clin. Pharmacol. Ther."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e114","DOI":"10.1016\/j.bja.2018.09.019","article-title":"Evidence of opioid-induced hyperalgesia in clinical populations after chronic opioid exposure: A systematic review and meta-analysis","volume":"122","author":"Higgins","year":"2019","journal-title":"Br. J. Anaesth."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1016\/j.amepre.2015.03.040","article-title":"Emergency Department Visits and Overdose Deaths From Combined Use of Opioids and Benzodiazepines","volume":"49","author":"Jones","year":"2015","journal-title":"Am. J. Prev. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e2120353","DOI":"10.1001\/jamanetworkopen.2021.20353","article-title":"Association Between Receipt of Overlapping Opioid and Benzodiazepine Prescriptions From Multiple Prescribers and Overdose Risk","volume":"4","author":"Chua","year":"2021","journal-title":"JAMA Netw. Open"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"737","DOI":"10.15585\/mmwr.mm6834a2","article-title":"Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines, Cocaine, and Methamphetamine\u201425 States, July\u2013December 2017 to January\u2013June 2018","volume":"68","author":"Gladden","year":"2019","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e180919","DOI":"10.1001\/jamanetworkopen.2018.0919","article-title":"Exposure-Response Association Between Concurrent Opioid and Benzodiazepine Use and Risk of Opioid-Related Overdose in Medicare Part D Beneficiaries","volume":"1","author":"Hernandez","year":"2018","journal-title":"JAMA Netw. Open"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"h2698","DOI":"10.1136\/bmj.h2698","article-title":"Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: Case-cohort study","volume":"350","author":"Park","year":"2015","journal-title":"BMJ"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"j760","DOI":"10.1136\/bmj.j760","article-title":"Association between concurrent use of prescription opioids and benzodiazepines and overdose: Retrospective analysis","volume":"356","author":"Sun","year":"2017","journal-title":"BMJ"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1136","DOI":"10.15585\/mmwr.mm7034a2","article-title":"Trends in Nonfatal and Fatal Overdoses Involving Benzodiazepines\u201438 States and the District of Columbia, 2019\u20132020","volume":"70","author":"Liu","year":"2021","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2433","DOI":"10.1001\/archinte.163.20.2433","article-title":"Depression and pain comorbidity: A literature review","volume":"163","author":"Bair","year":"2003","journal-title":"Arch. Intern. Med."},{"key":"ref_24","first-page":"100212","article-title":"Psychiatric symptoms and recent overdose among people who use heroin or other opioids: Results from a secondary analysis of an intervention study","volume":"10","author":"Fendrich","year":"2019","journal-title":"Addict. Behav. Rep."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1093\/pm\/pnx038","article-title":"Risk Factors for Serious Prescription Opioid-Induced Respiratory Depression or Overdose: Comparison of Commercially Insured and Veterans Health Affairs Populations","volume":"19","author":"Nadpara","year":"2018","journal-title":"Pain Med."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Richards, G.C., Mahtani, K.R., Muthee, T.B., DeVito, N.J., Koshiaris, C., Aronson, J.K., Goldacre, B., and Heneghan, C.J. (2020). Factors associated with the prescribing of high-dose opioids in primary care: A systematic review and meta-analysis. BMC Med., 18.","DOI":"10.1186\/s12916-020-01528-7"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1370\/afm.1885","article-title":"Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations","volume":"14","author":"Scherrer","year":"2016","journal-title":"Ann. Fam. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1097\/01.j.pain.0000460316.58110.a0","article-title":"Change in opioid dose and change in depression in a longitudinal primary care patient cohort","volume":"156","author":"Scherrer","year":"2015","journal-title":"Pain"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1532","DOI":"10.1002\/pds.5349","article-title":"Prevalence and distribution of high-risk prescription opioid use in the United States, 2011\u20132016","volume":"30","author":"McCormick","year":"2021","journal-title":"Pharmacoepidemiol. Drug Saf."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"273","DOI":"10.2147\/CIA.S1847","article-title":"Opiates and elderly: Use and side effects","volume":"3","author":"Chau","year":"2008","journal-title":"Clin. Interv. Aging"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1111\/add.13925","article-title":"Risk factors for severe respiratory depression from prescription opioid overdose","volume":"113","author":"Fox","year":"2018","journal-title":"Addiction"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2059","DOI":"10.1001\/jama.2019.5188","article-title":"Limits on Opioid Prescribing Leave Patients With Chronic Pain Vulnerable","volume":"321","author":"Rubin","year":"2019","journal-title":"JAMA"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1097\/01.TPM.0000505513.89504.6a","article-title":"Mixed Reaction from Professional Groups on CDC Opioid Guideline","volume":"32","author":"Elabd","year":"2016","journal-title":"Top. Pain Manag."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e2115328","DOI":"10.1001\/jamanetworkopen.2021.15328","article-title":"Clinical Knowledge and Trends in Physicians\u2019 Prescribing of Opioids for New Onset Back Pain, 2009-2017","volume":"4","author":"Gray","year":"2021","journal-title":"JAMA Netw. Open"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1601","DOI":"10.1038\/s41593-021-00924-3","article-title":"Pain induces adaptations in ventral tegmental area dopamine neurons to drive anhedonia-like behavior","volume":"24","author":"Markovic","year":"2021","journal-title":"Nat. Neurosci."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"103308","DOI":"10.1016\/j.drugpo.2021.103308","article-title":"Opioid dosing among patients with 3 or more years of continuous prescription opioid use before and after the CDC opioid prescribing guideline","volume":"97","author":"Salas","year":"2021","journal-title":"Int. J. Drug Policy"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1001\/jama.2021.11013","article-title":"Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids","volume":"326","author":"Agnoli","year":"2021","journal-title":"JAMA"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"881","DOI":"10.2105\/AJPH.2020.305620","article-title":"Laws Mandating Coprescription of Naloxone and Their Impact on Naloxone Prescription in Five US States, 2014-2018","volume":"110","author":"Green","year":"2020","journal-title":"Am. J. Public Health"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e196215","DOI":"10.1001\/jamanetworkopen.2019.6215","article-title":"Association of Naloxone Coprescription Laws With Naloxone Prescription Dispensing in the United States","volume":"2","author":"Sohn","year":"2019","journal-title":"JAMA Netw. Open"}],"container-title":["Pharmaceuticals"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1424-8247\/14\/12\/1279\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:42:56Z","timestamp":1760168576000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1424-8247\/14\/12\/1279"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,12,8]]},"references-count":39,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2021,12]]}},"alternative-id":["ph14121279"],"URL":"https:\/\/doi.org\/10.3390\/ph14121279","relation":{},"ISSN":["1424-8247"],"issn-type":[{"value":"1424-8247","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,12,8]]}}}