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.
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.
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.