04 Aug Limiting Prescriptions to Three Days and Using Short Acting Drugs May Decrease Opioid Dependency
MedicalResearch.com Interview with:
Richard A. Deyo MD, MPH
Kaiser Permanente Professor of Evidence-Based Family Medicine
Department of Family Medicine
Department of Medicine
Department of Public Health and Preventive Medicine
Oregon Institute of Occupational Health Sciences
Oregon Health and Science University
Portland, OR 97239
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Doctors and other prescribers often wonder how much and for how long they can prescribe opioids before inadvertently promoting long-term use. Unfortunately, few data are available to guide initial prescribing. Long-term opioid use is problematic because of substantial rates of dependence and misuse, and because the efficacy of long-term therapy remains unproven. Development of drug tolerance and increasing sensitivity to pain may limit long-term efficacy. Several factors may explain the emergence of inadvertent long-term use, including opioid dependence, recreational use, addiction, and illicit diversion to other users.
We studied the risk of long-term use (defined as filling 6 or more opioid prescriptions in the subsequent year) with data from Oregon’s Prescription Drug Monitoring Program, which captures all opioid prescriptions filled in Oregon pharmacies, regardless of who wrote the prescription or who paid for the prescription. We identified patients who had not received opioid medication in the previous year, but now received an initial prescription. There were over half a million such patients during the one-year study.
Our most informative analysis was among people under age 45, which excluded most patients with a diagnosis of cancer, who were near the end of life, or who had chronic painful conditions such as arthritis. In this group, a patient who received just a three day supply of a moderate dose of opioids (For example, 10 mg. of hydrocodone plus acetaminophen 4 times daily for 3 days) had about a 2% risk of becoming a long term user. Someone who filled two prescriptions jumped to a 7% risk.
Patients receiving a long-acting opioid as the first prescription had a higher risk of becoming long term users than those receiving short-acting opioids. Patients receiving a single prescription for such medications had almost a 16% likelihood of becoming long-term users compared to just 2% for those receiving short-term opioids. In some cases, long-term use may have been intended, but our exclusion of patients with cancer and end-of-life care made this less likely.
MedicalResearch.com: What should readers take away from your report?
Response: These data may be helpful for doctors trying to avoid inadvertently promoting long-term opioid use. They suggest the value of encouraging limited initial prescriptions, avoiding refills when possible, and using the Prescription Monitoring Program for identifying patients at higher risk of long-term use.
Our data lend support for the new CDC opioid prescribing guidelines, which suggests that just a three day supply of opioids is “often sufficient,” and that “more than 7 days will rarely be needed.”
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: An important issue is the degree to which patient characteristics predict long-term opioid use, as opposed to characteristics of the initial opioid prescribing. We had very little demographic or clinical information about the patients in the study, and there is a need for further research to understand the relative contributions of patient factors versus prescribing factors.
MedicalResearch.com: Is there anything else you would like to add?
Response: Other factors than the dose or duration of initial opioid prescribing can affect the likelihood of long-term opioid use. These include personal characteristics, genetics, mood disorders, and history of misusing other drugs or alcohol. Nonetheless, doctors have more control over high-risk prescribing, and our data may help their initial prescribing patterns.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
Richard A. Deyo, Sara E. Hallvik, Christi Hildebran, Miguel Marino, Eve Dexter, Jessica M. Irvine, Nicole O’Kane, Joshua Van Otterloo, Dagan A. Wright, Gillian Leichtling, Lisa M. Millet. Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study. Journal of General Internal Medicine, 2016; DOI: 10.1007/s11606-016-3810-3
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