How Doctors Start Patients on Opioids Influences the Probability of Long-term Use

By Michael Nguyen, PharmD
Director of Clinical Pharmacy

Michael NguyenThe maxim, “It’s not how you start, it’s how you finish” is a contrary proverb.  The central theme of this maxim is that a bad start to something does not always lead to a bad ending.  Like a boxer who is knocked down in the first round ends up winning the match or the racecar driver who qualifies last ends up winning the race.  A new study published by the Centers for Disease Control and Prevention shows that the characteristics of the first episode of opioid use have strong implications for whether or not a patient progresses to chronic use.  The study sought to quantify the transition from acute to chronic opioid use.  What factors during acute use increased the probability of chronic opioid use?

Initial Higher Day Supplies = Higher Rates of Long-Term Use

Almost 1.3 million randomly sampled patients were included in the study.  The study found that the overall average probability of chronic opioid use was relatively low for all patients (6.0% at 1 year and 2.9% at 3 years).  When the researchers looked at the days supplies that were prescribed during this initial episode, they found that higher day supplies correlated with higher rate of use 1 and 3 years later.  The type of opioid first used also presented some interesting correlations.

Using 6.0% as a baseline probability for all patients for use at 1 year and 2.9% for use at 3 years, the study findings showed that the probability of chronic use increases after the third day of the initial opioid prescription and sharply rises after the fifth day.  After the third day, the probability of chronic use increases beyond 6% and continues to rise from there.  For example, of the patients who were prescribed more than 8 days of opioids during the first episode, 13.5% were still using a year later and for those who were prescribed more than 31 days of opioids, 29.9% continued.

Initial Long-Acting Opioids = Higher Rates of Long-Term Use

In regards to the type opioid selected for the first episode, the study found patients who started with long-acting opioids had the highest probabilities of long-term use (27.3% at 1 year and 20.5% at 3 years).  Those who started with short-acting hydrocodone, short-acting oxycodone, and other Schedule III-IV opioids (e.g., codeine, buprenorphine, Pentazocine) showed similar probability of continued use at 1 and 3 years (approximately 4.6-5.1% for 1 year and 2.2-2.4% for 3 years).

Surprisingly, patients who started with tramadol showed the next highest probability of long-term use (13.7% at 1 year and 6.8% at 3 years).  More than 64% of patients initiated with tramadol were still on tramadol 1 year later.

The CDC Guideline for Prescribing Opioids for Chronic Pain (published on March 18, 2016) recommended the shortest duration possible when opioids are used to treat acute pain stating that, three days or less will often be sufficient; more than seven days will rarely be needed.”  When this recommendation was initially made by the CDC, it carried with it an evidence level of 4 because data regarding the transition from acute to chronic opioid use was lacking.  The findings from this study support the utility of the day supply limits recommended by the CDC.  According to the study report, exceeding 1 week or prescribing a second opioid prescription “approximately doubles the chances of use 1 year later.”

Meaningful Efforts to Combat Opioid Addiction

In response to the opioid epidemic, several states have enacted legislation to limit initial opioid prescriptions. Since the beginning of 2016, New York, Maine, Massachusetts, Connecticut, New Jersey, Indiana, and Utah have all limited initial opioid prescriptions to either 5 or 7 days, and Louisiana has 7-day legislation awaiting the governor’s signature.  At the federal level, the U.S. Senate is considering SB 892, which would enact a 7-day federal limitation.  These restrictions provide meaningful effort against the opioid epidemic although opponents view them as arbitrary measures that limit patient access to opioids.

At myMatrixx®, our prescriber outreach program has been educating doctors about the pitfalls of early prescribing and use of long-acting opioids for acute treatment for many years and has seen positive results in the form of more cautious prescribing of opioids.  Nationally, the rate of opioid prescribing has decreased by 10% from 2013 to 2015, with rates falling in every state except for South Dakota (2% increase).  It is our hope that research such as this continues to provide valuable insight into the problem of opioid use and changes the culture of opioid overutilization in America.