Will Strict Limits on Opioid Prescription Duration Prevent Addiction? Advocating for Evidence-Based Policymaking: Substance Abuse: Mallika L. Mundkur , MD, MPH, Adam J. Gordon , MD, MPH & Stefan G. Kertesz , MD, MSc – Jun 2017
Quick answer: NO!
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.
Unless you have a genetic disorder (EDS) or Fibromyalgia or CRPS or failed surgery…
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
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
All these studies count opioid doses as though they were a primary cause, instead of the result of serious pain. Pain is simply ignored in opioid
Pain is simply ignored in opioid studies, even though it’s the initiating cause.
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.
Does anyone besides Kolodny and PROP still believe that my opioid prescription is causing people to overdose on fentanyl mixed into the heroin they are shooting?
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 confusion between dependence and addiction is a deliberate ploy by anti-opioid activists to make ALL opioid USERS into ADDICTS.
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.