Will Limits on Opioid Rx Duration Prevent Addiction?

Will Strict Limits on Opioid Prescription Duration Prevent Addiction? Advocating for Evidence-Based Policymaking: Substance Abuse:  , MD, MPH,  , MD, MPH &  , 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.


12 thoughts on “Will Limits on Opioid Rx Duration Prevent Addiction?

  1. scott michaels

    thats exactly how unaware the cdc and tge doctors and others that wrote the guidelines.
    to an addict ZERO OPIOIDSi the only correct amount. 90 mg mme will just be a tease to tge addict. they will mosT likely finish a month supply in a few days.
    A CHRONIC PAIN PATIENT HIGH DOSE OR LOW DOSE IS DEPENDENT ON THE OPIOIDS FOR PAIN RELIEF. THAT IS WHY WHEN THE PATIENT IS GIVEN THE PROPER DOSE THEY MAKE IT LAST THE MONTH. IF THEY WERE ADDICTS 90 OR 900mg mme isnt enough. the will finish it quick mix with ither drugs or alcohol. THIS IS 2017 and should be common sense to the powers that be.
    WE ARE TALKING 2 distinctive types of sick people. punishing the dependent because of the addict is malpractice.

    Liked by 1 person

    1. Zyp Czyk Post author

      You are so right!

      This is so obvious to us, yet the Feds just cannot seem to understand how different the two situations are. Government stupidity is killing us.


  2. Candi Simonis

    This war on “opioids” is actually a war on chronic incurable diseases. A war on chronic pain disease patients who benefit from opioid medications. Medications that enable millions of Americans relief of chronic debilitating pain associated with these diseases.
    The fiction, widespread hysteria and distorted truths about this “opioid epidemic”, is killing legitimate chronic pain disease patients who use their medications responsibly. We are patients.
    100 million Americans have one or more chronic incurable pain Diseases. As the CDC, DEA, FDA, Medicaid and Medicare, and numerous other government agencies, are blaming Doctors for the over prescribing of opioid medication. NOBODY, is looking at or reading the statistics from chronic pain disease patients. How about NOT addressing these drugs as dangerous and addictive. When all else fails: physical therapy, exercise, over the counter medications and numerous injections etc, we chronic pain disease patients, are left with one option to help us cope, opioid pain medication. Lets address this medication as lifesaving and medically necessary for the million of Americans with chronic diseases. Chronic pain is a disease. Chronic pain disease patients are now the epidemic. The addiction rate of chronic pain disease patients is .02-.6 %. We do not misuse or abuse our medications.
    No other disease medication is scrutinized. We, as patients, are being denied, dismissed, overlooked and discriminated against, by our physicians, due to all the scrutiny associated with treating chronic pain disease with opioid medications. Our Dr’s are afraid to treat us humanely and adequately. We have a disease that medication is readily accessible and beneficial to us and we are being denied. We, pain patients, are being discriminated against, due to people who abuse illegal heroin and illegal fentanyl. This is a direct hunt for Doctors who prescribe life saving medication, for pain disease patients, that benefit from them. We have our privacy invaded, we no longer are able to have doctor/patient confidentiality. We now have insurance agencies, pharmacists, and other government agencies in our physicians offices, monitoring, prosecuting and policing our physicians.
    Though the statistics show a reduction in, opioid medications distributed, due to the CDC guidelines, death rates of overdoses from illegal opioids is rising.
    The specific causes of deaths also needs to be closely investigated. The opioid in the person’s system needs to be specified. Was it an illegal opioid, was it opioid medication specifically for that person, was there other drugs or alcohol involved? These statistics need to come out. These Government agencies do not want that information out, due to the fact that this “opioid epidemic”, would then be debunked.
    Let’s put the shoe on the other foot. Restricting or taking away our medications is like FORCING people who do not want this medication to take it. One day those against these medications will need them but they will be denied.
    We have a chronic disease. We want to be able to take care of our homes, our children, our selves, as much as possible, but without access to these life saving medications, we are unable to do so. We want to live, not just exist in pain 24/7.
    We need the government agencies to look at the real statistics, not the hand picked. These agencies are not physicians. They are trying to doctor us, patients, without a medical license. They are also trying to police our physicians. This is a war on a disease, medications, physicians and patients.
    We chronic pain disease patients need help. All the headlines, topics and stories on how opioids are bad and how people are abusing, misusing, overdosing, becoming addicted or dying from them. We need to look at the good they do and how they help our disease of chronic pain and the million of Americans who use them for some relief.
    The government needs to put the focus on illegal drugs coming into, being manufactured and distributed in this country, illegal fentanyl, illegal heroin, methamphetamine, cocaine and all other ILLEGAL DRUGS. Not the legally prescribed and medically necessary medications we patients need. We chronic pain disease patients need help, but we are helpless due to the government and government agencies. There is stigma, scrutiny and discrimination against us due to a category of medications we desperately need and benefit from, opioid medications.

    Liked by 1 person

    1. Zyp Czyk Post author

      If a policy isn’t working, just do it more!

      That’s how the drug-war functions, and ironically, it’s also the definition of insanity used in addiction treatment centers.


    2. Jerry Toman

      I’m a 59 year old man with five back surgeries including a fusion, my neck is fused with one screw backing out forcing my head down and both knees replaced. Despite this and the horrific chronic pain, my doctor sees fit to cut my morphine use to what he says are the FDA’S guideline of no more than 30mg daily. He doesn’t believe that the increased pain has left me with no quality of life let alone killing me slowly while I suffer as does my wife and rest of my family. I see suicide as the best option, but can’t do that to my family. He doesn’t believe me when I told him that two FDA pharmacists told me this 30mg limit is not true. His ego only got involved and dislikes what he said is putting pressure on him. I’m dying from chronic pain and have no recourse. On social security we can’t afford the alternative methods he recommends because neither comp insurance or medicare will pay for them. Signed, Suffering in Minnesota

      Liked by 1 person

      1. scott michaels

        Go to another dr. Medicare is approving chronic psin patients medication. Each state us different though. Cdc guidelines is 90mg mme.whiblch iis nothing. But u mudt find pain mgt dr that will support yoy

        Liked by 1 person

      2. Zyp Czyk Post author

        Kolodny has challenged the pain patient community to tweet him concrete examples of damage from forced opioid reductions, so your case is exactly what he’s looking for.

        Could you tweet this to @andrewkolodny?

        If not, may I have your permission to tweet him on your behalf?


  3. scott michaels


    Liked by 1 person

  4. John Lyman

    The opioid epidemic in Indiana has in part been the result of individuals struggling with pain management for chronic and acute pain conditions as well as doctors over prescribing the medication due to misleading information regarding the addictive nature of opioids from pharmaceutical companies. This epidemic can be eased with the increased use of Prescription Monitoring programs and requiring counseling and education for patients before opioids are prescribed. Additionally, decreasing the regulation barriers and wearisome insurer requirements on the development of opioid alternatives will help combat this crisis.

    The number of individuals who lack basic knowledge on opioids, their side effects and appropriate usage are great. Correcting this deficiency in knowledge will help curtail new individuals becoming addicted to opioids. What also compounds the problem is a lack of resources equipped to deal with a problem of this magnitude. Those who can acknowledge, even if to just themselves, that they need help, likely live too far away to feasibly receive it. Telephone counseling is a proven alternative to counseling in a clinical setting. Not only is it cost-effective, the retention of staying in counseling and treatment fidelity are encouraging as it allows for more flexibility for patients to fit sessions into their schedules. A research article titled, “Telephone-based continuing care counseling in substance abuse treatment: Economic analysis of a randomized trial” in Drug and Alcohol Dependence Journal found favorable results and stated that increasing the use of this mode of therapy should be considered.

    There is no one solution to fix the opioid problem in Indiana, but rather a combination of efforts, such as those detailed above that will attack multiple angles of the issue to hellp decrease the number of Hoosiers affected by opioid misuse.

    Shepard, Daley, Neuman, Blaakman, & McKay. (2016). Telephone-based continuing care counseling in substance abuse treatment: Economic analysis of a randomized trial. Drug and Alcohol Dependence, 159, 109-116.



Other thoughts?

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s