In the JournalsPerspective

Risk for chronic opioid use can be triggered in as little as three days

The likelihood of chronic opioid use in patients increased with each additional day of medication supplied starting with the third day and saw sharper increases as time went on, according to research recently published in Morbidity and Mortality Weekly Report.

“Data quantifying the transition from acute to chronic opioid use are lacking,” Anuj Shah, a PhD student in the division of pharmaceutical evaluation and policy, College of Pharmacy, University of Arkansas for Medical Sciences, and colleagues wrote.

To get more information on the subject, Shah and colleagues studied more than 1.2 million patient records randomly chosen from the IMS Lifelink+ database, which researchers said contains information on commercial health plan information from a large number of managed care plans and is representative of the U.S. commercially insured population . All the patients were aged 18 and older, had at least one opioid prescription from June 1, 2006, to Sept. 1, 2015 and were enrolled continuously for at least 6 months before their first opioid prescription.

Patients who had any cancer (besides nonmelanoma skin cancer) or a substance abuse disorder diagnosis in the 6 months before their first opioid prescription, or whose first prescription was for any buprenorphine formulation indicated for treatment of substance abuse were excluded. The patients were observed from the date of their first prescription until loss of enrollment, study end date, or discontinuation of opioids, which was defined as 180 days or more without opioid use.

The researchers found that the likelihood of chronic opioid use increased with each additional day of medication supplied starting with the third day, with sharper increases in chronic opioid use observed after the 5th and 31st day on therapy, after a second prescription or refill, a 700 morphine mg equivalent cumulative dose, and an initial 10- or 30-day supply. The highest probability of continued opioid use at 1 and 3 years was observed among patients who started on a long-acting opioid followed by patients who started on tramadol. In addition, patients who were older, female, had a pain diagnosis before opioid initiation, were initiated on higher doses of opioids, and were publicly or self-insured, were more likely to continue opioid therapy for 1 year or more compared with patients who discontinued opioid use in less than 365 days.

Previous research that recently appeared in the New England Journal of Medicine, suggests patients treated in the ED by physicians who prescribe opioids at a higher intensity are at greater risk for long-term opioid use than those who see low-intensity prescribers

“Transitions from acute to long-term therapy can begin to occur quickly: the chances of chronic use begin to increase after the third day supplied and rise rapidly thereafter. Consistent with CDC guidelines, treatment of acute pain with opioids should be for the shortest durations possible,” Shah and colleagues wrote. “In addition, prescribers should discuss the long-term plan for pain management with patients for whom they are prescribing either Schedule II long-acting opioids or tramadol.”

Other research recently identified six potential ways that could lead to better outcomes in chronic opioid management, including calculating progress toward achieving clinic objectives and pinpointing resources for complex patients. -by Janel Miller

Disclosure: Healio Family Medicine was unable to determine the researchers’ relevant disclosures prior to publication.

The likelihood of chronic opioid use in patients increased with each additional day of medication supplied starting with the third day and saw sharper increases as time went on, according to research recently published in Morbidity and Mortality Weekly Report.

“Data quantifying the transition from acute to chronic opioid use are lacking,” Anuj Shah, a PhD student in the division of pharmaceutical evaluation and policy, College of Pharmacy, University of Arkansas for Medical Sciences, and colleagues wrote.

To get more information on the subject, Shah and colleagues studied more than 1.2 million patient records randomly chosen from the IMS Lifelink+ database, which researchers said contains information on commercial health plan information from a large number of managed care plans and is representative of the U.S. commercially insured population . All the patients were aged 18 and older, had at least one opioid prescription from June 1, 2006, to Sept. 1, 2015 and were enrolled continuously for at least 6 months before their first opioid prescription.

Patients who had any cancer (besides nonmelanoma skin cancer) or a substance abuse disorder diagnosis in the 6 months before their first opioid prescription, or whose first prescription was for any buprenorphine formulation indicated for treatment of substance abuse were excluded. The patients were observed from the date of their first prescription until loss of enrollment, study end date, or discontinuation of opioids, which was defined as 180 days or more without opioid use.

The researchers found that the likelihood of chronic opioid use increased with each additional day of medication supplied starting with the third day, with sharper increases in chronic opioid use observed after the 5th and 31st day on therapy, after a second prescription or refill, a 700 morphine mg equivalent cumulative dose, and an initial 10- or 30-day supply. The highest probability of continued opioid use at 1 and 3 years was observed among patients who started on a long-acting opioid followed by patients who started on tramadol. In addition, patients who were older, female, had a pain diagnosis before opioid initiation, were initiated on higher doses of opioids, and were publicly or self-insured, were more likely to continue opioid therapy for 1 year or more compared with patients who discontinued opioid use in less than 365 days.

Previous research that recently appeared in the New England Journal of Medicine, suggests patients treated in the ED by physicians who prescribe opioids at a higher intensity are at greater risk for long-term opioid use than those who see low-intensity prescribers

“Transitions from acute to long-term therapy can begin to occur quickly: the chances of chronic use begin to increase after the third day supplied and rise rapidly thereafter. Consistent with CDC guidelines, treatment of acute pain with opioids should be for the shortest durations possible,” Shah and colleagues wrote. “In addition, prescribers should discuss the long-term plan for pain management with patients for whom they are prescribing either Schedule II long-acting opioids or tramadol.”

Other research recently identified six potential ways that could lead to better outcomes in chronic opioid management, including calculating progress toward achieving clinic objectives and pinpointing resources for complex patients. -by Janel Miller

Disclosure: Healio Family Medicine was unable to determine the researchers’ relevant disclosures prior to publication.

    Perspective
    • Primary care providers should read carefully “Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006-2015” by Shah et al, and reflect on its implications. The authors have extracted information from a large national database and presented associations of continued opioid use at 1 and 3 years with the quantity and duration of initial opioid therapy. One could draw conclusions that it is primarily these variables that result in individual patients ending up on long-term opioid therapy. However, clinicians must consider that these findings are correlations only. We don’t know how many were prescribed long-term opioids intentionally. For example, an individual might have [chronic kidney disease] and disabling osteoarthritis and a physician may choose to initiate long-term therapy with tramadol. In fact, a first prescription with tramadol correlated much more strongly with long-term opioid use then did a prescription with oxycodone or hydrocodone. Most who initiated with tramadol, if they did receive chronic therapy, continued to receive tramadol, a medication that most PCPs perceive as being of lower abuse potential than Schedule II opioids.

      Nevertheless, there are likely many individuals who are captured in this database for whom therapy was initially thought to be short-term who ended up on chronic therapy. PCPs have been advised by the CDC to avoid opioid therapy where possible and to use a short course and low doses when opioid therapy is needed. This information certainly supports the CDC’s caution in their Guideline for Prescribing Opioids for Chronic Pain.

      • Lawrence Greenblatt, MD
      • professor of medicine, community and family medicine, Duke University and co-chair, opioid safety committee, Duke Health
    • Disclosures: Healio Family Medicine was unable to confirm Greenblatt’s relevant financial disclosures prior to publication.