Analgesic Prescribing in Medically Complex Adult Outpatients Aged ≥40 Years: A Hierarchical Analysis of Comorbidity-Associated Patterns

Background/Objectives: Selecting appropriate analgesic therapy in patients with multimorbidity is increasingly challenging because clinicians must balance pain management against comorbidities, polypharmacy, and medication-related risks. However, evidence describing how analgesic prescribing patterns vary across patients with different multimorbidity profiles in routine outpatient practice remains limited. This retrospective cross-sectional study examined associations between multimorbidity and prescribing patterns across paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids, and identified clinical characteristics associated with different hierarchical analgesic exposure groups among adults aged ≥40 years in Saudi Arabia. Methods: Electronic health record data were analyzed for adults aged ≥40 years attending multiple clinics in the Eastern Region of Saudi Arabia between January 2020 and December 2021. Analgesic exposure at the index outpatient visit was classified using a hierarchical framework into mutually exclusive paracetamol-only, NSAID-priority, opioid-priority, or non-use groups. Multinomial logistic regression was performed to identify clinical characteristics associated with assignment to the hierarchical analgesic exposure groups. Results: Among 41,083 patients, 29,383 (71.5%) received at least one analgesic prescription at the index visit. The NSAID-priority group was the largest exposure category, followed by opioid-priority and paracetamol-only groups. Hierarchical analgesic prescribing patterns differed across patient clinical profiles, with prescribing observed across patients with cardiovascular, metabolic, gastrointestinal, respiratory, and neuropsychiatric disorders. In adjusted analyses, arthritis-related disease was associated with slightly higher odds of NSAID-priority assignment, whereas ischemic heart disease, gastritis-related disease, and respiratory disorders were associated with lower odds of NSAID-priority assignment. Constipation and urinary incontinence were associated with lower odds of opioid-priority assignment. Conclusions: Analgesic prescribing was common among medically complex adult outpatients aged ≥40 years, and hierarchical prescribing patterns differed across patient clinical and comorbidity profiles. The hierarchical framework provided a pragmatic approach for characterizing prescribing across major analgesic classes while accounting for concurrent exposure. Most disease-specific associations were attenuated after multivariable adjustment, and the remaining associations were generally modest in magnitude. Owing to the cross-sectional design and absence of detailed treatment-indication and pain-related information, these findings represent prescribing associations and should not be interpreted as evidence of causal prescribing decisions or treatment appropriateness.