Throughout the United States, greater attention is being paid to accidental overdoses from the long-term use of opioids. Experts have reported that there is an urgent need to better understand patterns of opioid prescribing. In most cases, healthcare providers do not prescribe opioids with the intent of having patients use them long term, nor do they intend to provide repeat prescriptions. “Opioids are an important drug class that is used to manage short-term pain as well as pain after surgical procedures or trauma,” explains W. Michael Hooten, MD. “At the same time, it’s critical that these medications are prescribed carefully to ensure their safe use by patients.”
Studies are lacking on the characteristics associated with the transition from shorter-term to longer-term opioid use, says Dr. Hooten. “When opioids are first prescribed, it’s unclear which patients are more likely to eventually receive repeat prescriptions,” he says. “A better understanding of these characteristics may help guide efforts to optimize opioid use. It could also help us anticipate the potential for inappropriate episodic or long-term use.”
Exploring Recent Trends
The Consortium to Study Opioid Risks and Trends (CONSORT) is an initiative supported by the National Institute of Drug Abuse that has identified trends and risks associated with long-term opioid therapy for chronic pain. CONSORT classified opioid prescribing patterns as 1) short-term use, 2) episodic use, and 3) long-term use. Dr. Hooten and colleagues had a study published in Mayo Clinic Proceedings that sought to determine how often patients receiving new opioid prescriptions progressed to episodic or long-term opioid use. It also examined associations between patient characteristics and the transition to longer-term use of opioids as defined by CONSORT.
For the analysis, researchers analyzed population-based drug prescription records for 1 year using the Rochester Epidemiology Project medical records linkage system. Patients with a new prescription for an opioid were followed through their medical records for 1 year after their initial prescription date. Overall, 293 patients received 515 new opioid prescriptions over the 1-year study.
Assessing Key Findings
“One of the most important findings from our analysis was that one in four patients who received a new opioid prescription progressed to episodic or long-term use of these drugs,” Dr. Hooten says. The investigation demonstrated that 21% of study participants progressed to an episodic prescribing pattern while 6% progressed to a long-term prescribing pattern.
The research team also found that substance abuse was significantly associated with a long-term opioid prescribing pattern when compared with a short-term pattern. Past or current nicotine use and substance abuse were identified as factors linked to episodic or long-term prescribing patterns as compared with a short-term pattern (Table). Depression, anxiety, and other psychiatric diagnoses were also associated with longer-term use in a univariate analysis, but they did not prove to be independent predictors in multivariable analyses because these conditions themselves are associated with substance abuse.
Analyzing the Implications
Previous studies have linked several factors to long-term postoperative opioid use in surgical patients, including younger age, lower household income, and preoperative opioid use, among others. Among ambulatory care patients, longer-term opioid use has been associated with a history of substance abuse, older age, being female, and depression. The study by Dr. Hooten and colleagues builds upon this existing data.
“Our observations have important clinical and research implications,” says Dr. Hooten. “Prescribers need to be aware of the factors that can lead patients to transition from short-term use of opioids to longer-term use. Our study suggests that patients with a history of substance abuse and nicotine use are at greater risk. Patients should be screened for past or current substance abuse and tobacco use before a new opioid prescription is initiated. This can help clinicians assess risks for longer-term prescribing. It also gives us an opportunity to counsel patients about these potential risk factors before an initial prescription is ever given.”
More Research Needed
According to Dr. Hooten, observations from the study need to be replicated in prospective analyses that also examine the role of pharmacological and behavioral interventions to reduce risks for long-term opioid use. “We’re still unsure about the effect that initial opioid doses and the duration of opioid exposure have on longer-term use of these drugs,” he says.
As more is learned about the clinical characteristics and potential underlying mechanisms associated with progression to long-term opioid use, it is possible that clinicians will be able to better identify at-risk patients. This information could also provide the basis for developing targeted clinical interventions to reduce longer-term use of opioids.
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 Proceed. 201;90:850-856. Available at: http://www.mayoclinicproceedings.org/article/S0025-6196(15)00345-6/fulltext.
Von Korff, M. Opioids for chronic musculoskeletal pain: putting patient safety first. Pain. 2013;154:2583-2585.
Katz, M.H. Opioid prescriptions for chronic nonmalignant pain: driving on a dangerous road. JAMA Intern Med. 2013;173:178.