Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study

Abstract

BACKGROUND: Long-term efficacy of opioids for noncancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use. OBJECTIVE: To examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients. DESIGN: Retrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges. PARTICIPANTS: Patients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients. MAIN MEASURES: Exposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation (Binitiation month^). Outcome: Proportion of patients with six or more opioid fills during the subsequent year (Blong-term users^). KEY RESULTS: There were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received < 120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs.CONCLUSIONS: Early opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.

Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine

“…32,33 Further, hospitalized patients frequently have fluctuating renal function and rapidly changing pain levels. We therefore recommend that initiation of long-acting opioids be avoided for treatment of acute, non-cancer pain in hospitalized medical patients.…”

Factors Influencing Long-Term Opioid Use Among Opioid Naive Patients: An Examination of Initial Prescription Characteristics and Pain Etiologies

“…Prior to these multivariate and subgroup analyses, it was unclear the extent to which persons with chronic pain were more likely to be prescribed higher quantities with more days supplied of opioids and thus confound previously reported relationships between days supplied and duration. 8,30 The results of the multivariate models and in particular the models including the interaction between pain etiology and days’ supply indicate that the days supplied independently contributes to the longer durations of opioids and this effect is not meaningfully modified by pain etiology (Figure 3.). For this reason, clinicians need to be aware that the days supplied of an initial opioid prescription may be the single most modifiable factor prognostic for continued opioid use when prescribing opioids.…”

“…Recently, two studies examined the influences of the initial prescribing characteristics on long term opioid use, however both of these studies lacked measures of pain etiology which would almost certainly influence the likelihood of long term opioid use. 8,30 The present study attempts to overcome this limitation and explores the association between characteristics of the first opioid prescription and the probability of opioid discontinuation among opioid naïve patients, controlling for patient level factors and the pain etiology for which an opioid was prescribed.…”

Commentary on Pardo (2017) and Moyo et al. (2017): Much still unknown about prescription drug monitoring programs

“…It is therefore incumbent upon us to make them as effective as possible, and to ensure that they do not simply shift opioid overdose from OAs to illicit opioids or cause other unintended negative outcomes, such as increases in untreated pain. PDMPs have limited utility in changing provider behavior at one of the most critical decision points, that of the initial opioid prescription for an opioid-naive patient [13]. They may be useful in identifying patients whose prescribing history marks them as at increased risk of overdose, but that risk will only be reduced if PDMP data triggers an appropriate clinical and public health response.…”