Opioid Rx Limits Will Not Prevent Addiction

Will Strict Limits on Opioid Prescription Duration Prevent Addiction? Advocating for Evidence-Based Policymaking – Mallika L. Mundkur , MD, MPH, Adam J. Gordon , MD, MPH & Stefan G. Kertesz , MD, MSc – June 20, 2017

In 2016, the Centers for Disease Control and Prevention (CDC) issued the first national guideline in the United States regarding opioid prescribing for pain.

The guideline included the recommendation that patients treated for acute pain should receive opioids for no longer than 7 days, prompting at least five states to implement laws requiring prescribers not to exceed this threshold when providing initial opioid supplies.

The rapid conversion of this guideline into policy appears to reflect an underlying assumption that limiting initial opioid supplies will reduce opioid consumption, and thus addiction.  

However, in the spirit of “evidence-based policymaking,” we write to caution against misreading the evidence.

Further, we recommend not resting addiction policy solely upon a platform of prescription opioid control.

At the time the CDC guideline was released, only limited data were available to support any specific threshold of days’ supplied of opioids.

While focused on chronic pain, the guideline’s inclusion of recommendations for acute pain was motivated by the stated notion that chronic pain management often begins with treatment of an acute episode of pain.

The recommendation of 7 days as an upper-limit was justified based upon consensus that acute pain syndromes typically resolve within this time frame, together with some data from observational studies associating initial post-operative opioid use following minor surgeries with persistent use.

One recently published study has been interpreted by some as providing data in support of stricter limits on opioid prescribing:

Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use- United States, 2006–2015. Morbidity and Mortality Weekly Report

The authors examined over one million adults with an apparent first prescription for opioids in an insurance database, observing a 6% and 2.9% probability of “continued use” at one and three years, respectively.

While not explicitly defined by the authors, based upon the study’s definition of discontinuation (i.e. “≥ 180 days without opioid use”), we infer that as few as two prescriptions following an initial episode of use might qualify as “continued use” at one year.

Longer initial prescriptions were associated with greater likelihood of continued use one and three years later with the greatest increase in continued use when the initial opioid supply exceeded 10 or 30 days, and “substantial” increased probability of use with prescription duration of 6 days.

The report concludes:

“the chances of chronic use begin to increase after the third day supplied and rise rapidly thereafter” and that “caution…be exercised when prescribing > 1 week of opioids.”

It should be noted that the study used the expressions “continued use” and “chronic use” interchangeably, with most literature defining “chronic use” more specifically—at least ten prescriptions or the equivalent of a 120 days’ supply in the year following an initial episode of use

Furthermore, the definition of continued use in this study would not fulfill diagnostic criteria for addiction, which previous research suggests will emerge among 0.7–6.1% of persons who receive opioids on a chronic basis.

The lack of information concerning patient needs or physician intention substantively weakens inferences regarding the true incidence of chronic use after acute opioid exposure.

Without accounting for diagnosis or prescribing intent, prescription duration cannot necessarily be inferred to have caused long-term opioid receipt

A more definitive exploration of the relation between initial prescription and long-term use would assess prescribing intent (i.e. short vs. long-term) and the range of patient and prescriber-level factors that influence prescribing, such as patient diagnosis, mental or physical comorbidities.

Finally, optimal research on opioid prescribing duration should utilize definitions of persistent or chronic use that are standard for the field

Unduly broad inferences drawn from this study have fueled the sentiment that short-term opioid exposure is a major contributor to addiction.

The intense focus on prescribing as the nidus for policy interventions reflects a hope that today’s opioid addiction crisis will be reversed by restricting the prescription opioid supply.

Such efforts are likely to obtain less traction now that other opioids such as heroin and illicitly manufactured fentanyl have come to dominate the crisis while receiving comparatively little attention from regulators and public health officials.

As legislators and regulators pursue two new numeric targets—prescribed days of pills and morphine milligram equivalents— they do so without prospective data to show what results these initiatives will yield.

With increasing anecdotal reports of harm to patients summarily cut off from opioids, there is some reason for concern.

There are no trials showing that addiction itself is averted based on 2 versus 8 days of opioids for a patient seen in an emergency room.

Similarly, no prospective data show that involuntary opioid taper or discontinuation in stable pain patients is to their benefit, even as we have witnessed a tide of reports of suicide and paradoxical overdose

On whole, the study provides a useful description of incident rates of long-term use, but it does not clarify risk of long-term dependence or addiction due to short-term exposure

Complicating matters, publicity surrounding the growing body of research on opioids has tended to deploy imprecise and stigmatizing language, resulting in blunt policies that adversely impact all patients who consume opioids, including those suffering from chronic pain, addiction, or both

As a result, terms with distinct meaning, such as opioid dependence and opioid addiction are conflated in the public mind, the former being an expected consequence of long-term opioid use, the latter requiring specific diagnostic criteria, such as compulsive use despite harm.

The CDC Guideline recommends an individualized assessment of harm against benefit in the care of patients with pain, while urging expanded access to addiction treatment, a perspective we endorse.

Strict legal prohibitions on prescriptions exceeding 3, 5 or 7 days violate this aspect of the Guideline and reach far beyond the available data, putting patients at risk.

While evidence-based policy-making may not always be possible, in such scenarios it becomes even more important to critically review data as it becomes available.

We must continue to attempt to understand the risks of physical dependence and addiction, and dedicate efforts to developing novel treatment strategies.

But the human impulse to show that we are “doing something” absent strong evidence can be harmful.

The references for the article below (some of which I’ve blogged already) are excellent articles in themselves, giving proof that the common perceptions about the dangers of opioids are wrong.

REFERENCES
Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. Morbidity and Mortality Weekly Report [Internet]. 2016 Mar [cited 2017 May 22]; 65(1); 1–49. Available from: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.
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Huff C. States aim to limit opioid prescriptions. ACP Internist, American College of Physicians [Internet]. 2016 Oct [cited 2017 May 22]. Available from: https://acpinternist.org/archives/2016/10/laws.htm.
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Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use- United States, 2006–2015. Morbidity and Mortality Weekly Report [Internet]. 2017 Mar [cited 2017 May 22]; 66(10):265–269.
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Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA Intern Med. 2016 Sep 1;176(9):1286–93. doi: 10.1001/jamainternmed.2016.3298.
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Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 2014 Jul;30(7):557–64. doi: 10.1097/AJP.0000000000000021.
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Frostenson, Sarah. “The risk of a single 5-day opioid prescription, in one chart.” Vox News [Internet]. Mar 18, 2017 [cited 2017 Jun 13]. Available from: https://vox.com/2017/3/18/14954626/one-simpleway-to-curb-opioid-overuse-prescribe-them-for-3-days-or-less
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Martins SS, Sarvet A, Santaella-Tenorio J, Saha T, Grant BF, Hasin DS. Changes in US Lifetime Heroin Use and Heroin Use Disorder: Prevalence From the 2001–2002 to 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017 May 1;74(5):445–455. doi: 10.1001/jamapsychiatry.2017.0113.
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Albritten, Deanna. “Fox59 investigates: VA hospital in Marion abruptly cutting opiateprescriptions.” Fox 59 news [Internet]. May 23, 2017 [cited2017 May 25]. Available from: http://fox59.com/2017/05/23/fox59-investigates-va-hospital-in-marion-abruptly-cutting-opiate-prescriptions/
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Kertesz SG, Gordon AJ. Strict limits on opioid prescribing risk the ‘inhumane treatment’ of pain patients. STAT News [Internet]. February 24, 2017 [cited 2017 May 25]. Available from: https://www.statnews.com/2017/02/24/opioids-prescribing-limits-pain-patients/
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5 thoughts on “Opioid Rx Limits Will Not Prevent Addiction

  1. leejcaroll

    If youre going to get addicted youre going to get addicted. Limiting makes no sense. If they are an addictive personality, genetically predisposed giving them 5 will not change their chances of becoming addicted. Silliness And youre right doing something just so it seems you are doing something is assinine

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    1. Zyp Czyk Post author

      The conflation of pain medication tablets with injected heroin has been ridiculous from the start, but PROP grabbed the media spotlight with their pain pills = heroin meme.

      To be consistent, they must then also conflate physical dependence on pain medication with addiction to the euphoria of a heroin injection.

      These are the pillars of their campaign and I don’t know how many suicides it’s going to take to shake them loose. Reason has little effect, as has been proven by the latest psychology studies, and only causes them to be more vehemently wrong.

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  2. scott michaels

    the cdc needs to read a narcotics annonomys or AA BOOK. addiction is a desease of the mind and sole. a gene if addiction essentially.
    a young oerson may not know they have this issue until its too late. adults know. example they cant stop once they start like the smoker for 30 yrs just quits.no problem. then the other person that needs pTches gum etc and still relapses. opioids are no different. hiwever chronic pain patients generally are not addicted or they woukd be in the doctors office weekly. with excuses why they ran out.
    chronic patients know they must make the medicine last 30 days. an addict cant do that.
    they would be out of a 30 day suppluly in a day or a week or so. WHEN THE DOSAGE IS CORRECT. NOW THAT THE CDC IS TELLING DOCTORS TO FORCABLY REDUCE THE MEDICATION. THE PATIENTS PAIN IS NATURALLY INCREASING. NOW THE PATIENT HAS TWO CHOICES. LIVE IN OAIN OR BUY FROM THE STREETS MOST AGED ADULTS WONT HIT THE STREETS. SO THEY LIVE IN PAIN AS LONG AS POSSIBLE. WHEN IT IS JUST UNVEAEABLE ANY MORE AND THE DOCTORS WONT GELP AND SOCIETY SHUNS THEM, MASSIVE DEPRESSION SETS IN AND THAT GOOD PERSON THAT WAS LIVING A KIFE OF MINIMAL PAIN BECAUSE IFBTHE SUCCESS IF OPIOID THERAPY DECIDESTO END THEIR LIFE IS THE LIFE OF A JUNKIE WHO MADE BAD CHOICES, DIDNT RECOGNIZE THE PROBLEM THEY HAD MORE IMPORTANT THEN THAT OFTHETRYE PAIN PATIENT. THOSE WITH CHRONIC PAIN AS QUOTED BY KAISER PERMANENTE ARE JUST COLLATERAL DAMAGE. THEY ALSO GET TO SAVE BILLIONS OF DOLLARS AT TGE SAMR TIME. IT AHOULD VE TGE ADDUCT THATS THE COLLATERAL DAMAGE BECAYSE IFYOU TAKE EVERY PAIN PILL OFF THE MARKET THE ADDICT WILL USE HEROIN WHICG AS U KNOW HAS BEEN AROUND FOR CENTURIES AND OYR GOVT CANT AND WONT EVER STOP THAT DRUG FORM COMING IN. EVEN IF THEY COUKD JUNKIES ABD DEALERS WOULD GRIW THEIR OWN POPPYS AND RXTRACT THE OPIUM. WILL THUS GOVT EVER FET A CLUE TO WHATS REALLY HAPPENINGBBELOW THEIR IVORY TOWERS?

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      1. scott michaels

        yes they do. chrinic pain is like going thru 4 wisdom teeth being pulled every day. the medicacion takes 90%of that pain away. the MORONS AT THE CDC SIS NOT TAKE INTO ACCOUNT CHRONIC PAIN PATIENTS AN THE FACT THAT TJEY ALL NEED DIFFERENT DOSES.
        THE MAIN PEOPLE THEY LISTENED TO WERE REHAB DOCTORS. THE ONES THAT NOW TAX PAYERS ARE PAYING FOR AND OPENING ON EVERY BLOCK. IF YOU WERE A DIABETOC AND JUNKIES COULD FIGURE OUT A WAY TO GET LOADED ON INSULIN AND OVER SOSE, SBOULD THEY TAKE YOURS AWAY. EVEN THOUGH YOU DONT ABUSE IT AND YOU ONLY TAKE IT AS DIRECTED. ITS SHEEP LIKE YOU THAT BELIEVE THOSE NAIVE IDIOTS. THE PROBLEM IS AND ALWAYS HAS BEEN HEROIN. FOR 7 YEARS ADDICTA WERE ABLE TO GET LEFGAL PRESCRIPTIOMS BECAUSE OF GREEDY DOCTORS. That is 99% over. Between date bases to atop dr shopping. bad dra out of business. it is very very jard to get a prescription filled. DRUG ADDICT NOW GO THE EASY ROUTE HEROIN. ITS EASY TO GET ITS PURE AND ITS MAYBE 80% cheaper. NOW WE HAVE GOOD PEOPLE LIVING IN SEVERE PAIN. ITS SO BAD MANY ELDERY ARE ENDING THEIR LIVES.
        YOU ARE SO WRONG. DONT U SEE THAT INSURANCE COMPANIES AND HMOS ONLY SEE THE BILLIONS OF DOLLARS THEY ARE SAVING IN PRESCRIPTIONS. THATS WHAT TJEY CARE ABOUT. I HAVE BEEN A HIGH DOSE PATIENT FOR A DECADE. 5 DOCTORS SAY MEDICALLY NESESSARY. NO OTHER PROCEDURE WORKED. NOW WITGOUT EVEN 1 exam its not medically neaessary.. the ycut so much i am bedridden once again
        if i have 1 hour of activity i feel blessed. I was able to go to disneyland work a few houra a day
        Now Nothing.. So the so called great cdc minds got paid off or.jist followed the obama politkical will. SAD NEWS HEROIN IS SELLING GREATER THEN EVER. PEOPLE DROPPING LIKE FLIES. IS THAT BETTER FOR YOU. MORON

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