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

  • Anuj Shah
    Affiliations
    Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas
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  • Corey J. Hayes
    Affiliations
    Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas

    Division of Health Services Research, Psychiatric Research Institute, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas
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  • Bradley C. Martin
    Correspondence
    Address reprint requests to Bradley C. Martin, PharmD, PhD, Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, 4301 W Markham St, slot 522, Little Rock, AR 72205.
    Affiliations
    Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas
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      Highlights

      • Patients with chronic pain had the highest probability of continued opioid use.
      • Long-term opioid use was uncommon for other conditions (<7% at 1 year).
      • Initiation with tramadol or long-acting opioids increases likelihood of continued use.
      • The days supplied for the first opioid prescription is the strongest predictor of continued opioid use.

      Abstract

      The relationships between the initial opioid prescription characteristics and pain etiology with the probability of opioid discontinuation were explored in this retrospective cohort study using health insurance claims data from a nationally representative database of commercially insured patients in the United States. We identified 1,353,902 persons aged 14 years and older with no history of cancer or substance abuse, with new opioid use episodes and categorized them into 11 mutually exclusive pain etiologies. Cox proportional hazards models were estimated to identify factors associated with time to opioid discontinuation. After accounting for losses to follow-up, the probability of continued opioid use at 1 year was 5.3% across all subjects. Patients with chronic pain had the highest probability for continued opioid use followed by patients with inpatient admissions. Patients prescribed doses ≥90 morphine milligram equivalents (hazard ratio [HR] = .91; 95% confidence interval [CI], .91–.92), initiated with tramadol (HR = .89; 95% CI, .89–.90) or long-acting opioids (HR = .79; 95% CI, .77–.82) were less likely to discontinue opioids. Increasing days' supply of the first prescription was consistently associated with a lower likelihood of opioid discontinuation (HRs, CIs: 3–4 days' supply = .70, .70–.71; 5–7 days' supply = .48, .47–.48; 8–10 days' supply = .37, .37–.38; 11–14 days' supply = .32, .31–.33; 15–21 days’ supply = .29, .28–.29; ≥22 days supplied = .20, .19–.20). The direction of this relationship was consistent across all pain etiologies. Clinicians should initiate patients with the lowest supply of opioids to mitigate unintentional long-term opioid use.

      Perspective

      This study shows that characteristics of the first opioid prescription, particularly duration of the prescription, are significant predictors of continued opioid use irrespective of the indication for an opioid prescription. These data should encourage prescribers to initiate patients using the minimum effective opioid dose and duration to reduce unintended long-term use and could motivate policies that restrict the initial supply of opioids.

      Key words

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