The Opioid Tunnel

Shoshanna Robinson, Mercer University College of Pharmacy

The Centers of Disease Control and Prevention (CDC) guidelines on  prescribing opioids for chronic pain suggests that early opioid prescribing patterns for opioid-naïve patients increases the likelihood of long-term use. [1]  However, data is limited regarding the transition from acute to chronic opioid use.  The objective of this CDC morbidity and mortality report was to analyze the probability of long-term opioid use after an initial opioid prescription. [2]

Approximately 10% of randomized patient records from the IMS Lifelink+ database were analyzed to characterize the first episode of opioid use among commercially insured, opioid-naïve, and cancer-free adults.  Paid out-of-pocket prescriptions and illicit opioids were not included.   Records were reviewed from June 1st, 2006 to September 1st, 2015.  The increased probability of long-term use was quantified by each additional day supply, days of therapy, or cumulative dose increases.  Patients were followed from their first prescription until loss of enrollment, study end date, or discontinuation of opioids (≥180 days without opioid use). [2]

A total of 1,294,247 patients were analyzed, in which, 33,548 (2.6%) continued opioid therapy for 1 year or more.   Approximately 70% of patients had an initial opioid duration of 7 days or less and 7.3% were initially prescribed opioids for 31 days or more.  The probability of continued opioid use increased with the first prescription of a 10 or 30 day supply, a 3rd opioid prescription, or a cumulative dose of 700 or more morphine milligram equivalents. [2]

 Table 1. Probabilities of continued opioid use among opioid-naïve patients in the first     episode of opioid use

1-year 3-year
Probability of continuing opioid use (%) 6.0 2.9
Median time to discontinuation, days 7 7

Table 2. Probabilities of continued opioid use by choice of first opioid of first opioid prescription

Choice of first prescription 1-year probability of continued use 3-year probability of continued use Median time to discontinuation, days
Long-acting opioid (%) 27.3 20.5 63
Tramadol (%) 13.7 6.8 25
Schedule II short-acting opioid (%) 8.9 5.3 5
Hydrocodone Short Acting (%) 5.1 2.4 5
Oxycodone Short Acting (%) 4.7 2.3 6
Schedule III-IV and Nalbuphine (%) 5.0 2.2 6

The rate increased to 13.5% for patients with first opioid use for 8 days or more and to 29.9% when the first opioid use was for 31 days or more.  It was stated that the probability of long-term opioid use increases most sharply in the first days of therapy, particularly after 5 days or 1 month of opioids have been prescribed.  The highest probabilities of chronic opioid use was associated with long-term opioids. [2]

Pain etiology in the study was unknown, which can influence the duration of opioid use.  Total cumulative doses were calculated, which might have been increasing or decreasing over time.  Prescribers and pharmacists should make decisions on risk benefit stratification for the need of a second opioid prescription.  Opioid duration less than 7 days is recommended by the CDC guidelines.  Health care providers can begin with prescriptions of only a few days to prevent unintentional chronic opioid use and to accurately evaluate whether or not follow-up prescriptions are necessary.

References

[1.] Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1).

[2.] Shah, A., Hayes, C., & Bradley, M. (2017, May 17). Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use. Retrieved April 9, 2017, from https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm

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