Saturday, March 18, 2017

Opioid Abuse

The CDC in this weeks MMWR notes:

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, and levels off after approximately 12 weeks of therapy. The rate of long-term use was relatively low (6.0% on opioids 1 year later) for persons with at least 1 day of opioid therapy, but increased to 13.5% for persons whose first episode of use was for ≥8 days and to 29.9% when the first episode of use was for ≥31 days. Although ≥31 days of initial opioid prescriptions are not common, approximately 7% do exceed a 1-month supply. Discussions with patients about the long-term use of opioids to manage pain should occur early in the opioid prescribing process, perhaps as early as the first refill, because approximately 1 in 7 persons who received a refill or had a second opioid prescription authorized were on opioids 1 year later. As expected, patients initiated on long-acting opioids had the highest probabilities of long-term use. However, the finding that patients initiated with tramadol had the next highest 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  

The results are below:

and also:

They conclude: 

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. Consistent with CDC guidelines, treatment of acute pain with opioids should be for the shortest durations possible. Prescribing 1 week of opioids or when authorizing a refill or a second opioid prescription because these actions approximately 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.

This is a significant and important result. All physicians for license renewal must take a course and be tested on dealing with opioid abuse. Hydrocodone and Oxycodone have been distributed somewhat freely in the past and their impact not fully understood. Today with the above results as a start much more careful handling is essential.