Rapid Shift to Long-term Opioid Use After Initial Prescription

Megan Brooks

March 17, 2017

For patients who need an initial opioid prescription, supplying 3 or fewer days' worth of medication reduces the likelihood of long-term opioid use, new data show.

In a large representative sample of opioid-naive, cancer-free adults who received a first prescription for opioid pain relievers, the likelihood of long-term opioid use increased with each additional day of medication supplied, starting with the third day, the study team found.

"Knowledge that the risks for chronic opioid use increase with each additional day supplied might help clinicians evaluate their initial opioid prescribing decisions and potentially reduce the risk for long-term opioid use," the authors, led by Bradley Martin, PharmD, PhD, at the University of Arkansas for Medical Sciences in Little Rock, write.

"Discussions with patients about the long-term use of opioids to manage pain should occur early in the opioid prescribing process," they advise in the Morbidity and Mortality Weekly Report of March 17.

Risky Business

Among nearly 1.3 million new opioid users in the IMS LifeLink+ database, about 2.6% continued opioid therapy for 1 year or longer. These patients were more likely to be older, female, to have a pain diagnosis before starting treatment with an opioid, and to receive higher initial doses of opioids compared with patients who discontinued opioid use before the 1-year mark.

Among patients prescribed at least 1 day's supply of opioids, the rate of long-term use was relatively low (6.0% taking opioids 1 year later, 2.9% taking opioids 3 years later).

However, the rate of long-term use increased to 13.5% for patients who used opioids initially for 8 days or longer, and to 29.9% when the first-use episode lasted for 31 days or longer.

Overall, in this cohort, roughly 70% of patients were prescribed opioids for 7 days or less, but about 7% were initially prescribed opioids for 31 days or more.

The largest incremental increases in long-term opioid use occurred in patients whose initial supply exceeded 10 or 30 days, in those for whom a second prescription was authorized or refilled, and in those whose cumulative opioid dose was 700 morphine mg equivalents or higher, the researchers found.

The highest probability of continued opioid use at 1 and 3 years was in patients who were initially prescribed a long-acting opioid (27.3% at 1 year and 20.5% at 3 years), followed by those who initially received tramadol (13.7% at 1 year and 6.8% at 3 years) or who received a Schedule II short-acting opioid other than hydrocodone or oxycodone (8.9% at 1 year and 5.3% at 3 years).

Tramadol Also a Concern

There were no differences in the probability of continued opioid use at 1 and 3 years for individuals who were initially prescribed short-acting hydrocodone (5.1% at 1 year and 2.4% at 3 years), short-acting oxycodone (4.7% at 1 year and 2.3% at 3 years), or a Schedule III-IV opioid (5.0% at 1 year and 2.2% at 3 years).

Dr Martin and colleagues say the finding that patients who were initially prescribed tramadol had a high probability of long-term use was "unexpected." Because of tramadol's minimal affinity for the μ-opioid receptor, it is deemed a "relatively safe opioid agonist with lower abuse potential than other opioids," they point out. However, a recent report from the Substance Abuse and Mental Health Services Administration did show that emergency department visits associated with tramadol-related adverse events increased by 145% during 2005-2011.

Overall, the findings from this analysis have implications for public health, the authors say.

"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," they write.

Consistent with guidelines from the Centers for Disease Control and Prevention, treatment of acute pain with opioids should be for the shortest duration possible. Prescribing fewer than 7 days' worth (ideally, 3 days' worth or less) of medication when starting opioids could lessen the chances of unintentional long-term use, they say.

When initiating opioids, "caution should be exercised" when prescribing more than 1 week's worth of opioids or when authorizing a refill or a second opioid prescription, because these actions roughly double the chances of use 1 year later.

"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," they conclude.

Morb Mortal Wkly Rep (MMWR). 2017;66:265-269. Full text


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.