CME/CE: Initial Opioid Use & Long-Term Risks

CME/CE: Initial Opioid Use & Long-Term Risks
Author Information (click to view)

Richard A. Deyo, MD, MPH

Kaiser Permanente Professor of Evidence-Based Family Medicine
Professor of Medicine, Public Health, & Preventive Medicine
Investigator, Oregon Institute for Occupational Health Sciences
Oregon Health and Science University
Clinical Investigator
Kaiser Northwest Center for Health Research

Richard A. Deyo, MD, MPH, has indicated to Physician’s Weekly that he has or has received royalties from UpToDate for authoring topics on low back pain, and previously received honoraria for board membership at the non-profit Informed Medical Decisions Foundation. His salary at Oregon Health & Science University is supported in part by an endowment from Kaiser Permanente. He received a financial award from NuVasive as part of a lifetime achievement award from the International Society for the Study of the Lumbar Spine.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians and nurses.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

 

  • Describe the findings of a retrospective data analysis that examined the link between initial opioid prescribing patterns and the likelihood of subsequent long-term use.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwJan0117.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

Physician Assistants

NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.

 

Nursing

AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This activity is awarded 0.5 contact hours.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Richard A. Deyo, MD, MPH
Discloses no financial relationships with pharmaceutical or medical product manufacturers:
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Richard A. Deyo, MD, MPH (click to view)

Richard A. Deyo, MD, MPH

Kaiser Permanente Professor of Evidence-Based Family Medicine
Professor of Medicine, Public Health, & Preventive Medicine
Investigator, Oregon Institute for Occupational Health Sciences
Oregon Health and Science University
Clinical Investigator
Kaiser Northwest Center for Health Research

Richard A. Deyo, MD, MPH, has indicated to Physician’s Weekly that he has or has received royalties from UpToDate for authoring topics on low back pain, and previously received honoraria for board membership at the non-profit Informed Medical Decisions Foundation. His salary at Oregon Health & Science University is supported in part by an endowment from Kaiser Permanente. He received a financial award from NuVasive as part of a lifetime achievement award from the International Society for the Study of the Lumbar Spine.

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As opioid prescribing has increased over the past two decades, the United States healthcare system has also seen rising rates of overdoses and addiction treatment resulting from misuse and abuse of these drugs. “Experts have called for more selective use of opioids, but clinicians are often left wondering how long and how high a dose of opioids can be prescribed before inadvertently promoting long-term use,” says Richard A. Deyo, MD, MPH. Greater attention is needed regarding the characteristics of initial and early opioid prescriptions and their association with long-term use.

 

Examining the Link

Few data are available to guide initial prescribing for opioid-naïve patients. For a study published in the Journal of General Internal Medicine, Dr. Deyo and colleagues retrospectively analyzed data from Oregon’s prescription drug monitoring program. “Our goal was to examine the link between initial opioid prescribing patterns and the likelihood of subsequent long-term use,” says Dr. Deyo. “This data could help clinicians minimize their risk of inadvertently initiating long-term opioid use.”

The study involved opioid-naïve patients and examined information on their prescriptions death certificates, and hospital discharges. Exposure to opioids was defined as the number of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days after these drugs were initiated. Long-term users were defined as patients who filled an opioid prescription six or more times during the subsequent year.

 

Identifying Associations

Results of the analysis showed that about 5% of the more than 536,000 opioid-naïve patients who filled a prescription for these medications became long-term users. The vast majority—about 80%—received one prescription fill in the initiation month, and nearly 3% of this group became long-term opioid users.

Many patients received two or more prescription fills during the initiation month. Among patients with two fills, nearly 11% became long-term opioid users. For those with four or more fills, about 26% became long-term users. The number of opioid prescriptions filled and cumulative MMEs during the initiation month were associated with long-term use (Table). Among patients younger than 45 who filled two short-acting opioid prescriptions and did not die in the follow-up year—thus excluding most cancer or palliative care patients—long-term use of opioids was more than twice as likely when compared with those who filled just one prescription.

“Our findings occurred even when patients were receiving fairly low doses of prescription opioids,” Dr. Deyo says. When compared with those receiving less than 120 total MMEs, patients receiving between 400 and 799 total MMEs were nearly three times as likely to become long-term users. Patients who were started on long-acting opioids had a higher risk of long-term use than those who were initiated with short-acting drugs.

 

Considering Implications

According to Dr. Deyo, the study supports the importance of taking precautions when using long-acting opioids as initial therapy. “For most patients started on opioids, the intent is to use them for a short duration,” he says. “Our study suggests that it may be possible to reduce the risks associated with long-term opioid use by initiating patients on a single prescription of a short-acting opioid. This prescription should be restricted to no refills and a cumulative dose of less than 120 MMEs.” He adds that the increasing risk of long-term opioid use—even at low cumulative doses—supports recent recommendations from the CDC to limit this therapy to 3 to 7 days for most patients.

With the opioid epidemic gaining more attention throughout the U.S., many physicians have focused efforts on managing patients who are deemed high risk for abuse or misuse of these drugs. “Our analysis shows that we need to consider initial opioid prescribing patterns when we try to characterize patients who may be at risk for the adverse effects of these powerful drugs,” says Dr. Deyo. “Clinicians have no control over patient characteristics, but have great control over initial opioid prescribing.”

Physicians should recognize the value of greater attention to high-risk prescribing patterns, according to Dr. Deyo. “Our hope is that our findings will help doctors in their quest to reduce risks of patients using these medications for the long term,” he says. The study group noted that the data also highlight the importance of monitoring opioid refills and subsequent prescriptions for all patients, not just those who may be at risk of abuse or misuse.

Readings & Resources (click to view)

Deyo RA, Hallvik SE, Hildebran C, et al. Association between initial opioid prescribing patterns and subsequent long-term use among opioid-naïve patients: a statewide retrospective cohort study. J Gen Intern Med. 2017;32:21-27. Available at: http://link.springer.com/article/10.1007/s11606-016-3810-3.

Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA. 2016;315:1624-1645.

Gwira Baumblatt JA, Wiedeman C, Dunn JR, Schaffner W, Paulozzi LJ, Jones TF. High-risk use by patients prescribed opioids for pain and its role in overdose deaths. JAMA Intern Med. 2014;174:796-801.

Hooten WM, St. Sauver JL, McGree ME, Jacobson DJ, Warner DO. Incidence and risk factors for progression from short-term to episodic or long-term opioid prescribing: a population-based study. Mayo Clin Proc. 2015;90:850-856.

Dowell D, Kunins HV, Farley TA. Opioid analgesics – risky drugs, not risky patients. JAMA. 2013;309:2219-2220.

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