NEW YORK (Reuters Health) – The length of a postsurgical opioid prescription for an opioid-naive patient predicts the risk of misuse much more strongly than the dose prescribed, new findings show.
Each additional refill increased the likelihood of opioid misuse by over 40%, while misuse increased by 20% for every additional week of opioid use, Dr. Gabriel A. Brat of Harvard Medical School, in Boston, and colleagues found. They reported their findings online January 17 in The BMJ.
There has been no guidance for surgeons on postoperative prescribing of opioids, the researchers note. Up to 10% of opioid-naive patients become chronic users, they add, while an estimated 80% of pills prescribed may not be used.
Dr. Brat and his colleagues analyzed administrative data on nearly 38 million people covered by Aetna, a U.S.-based managed-healthcare company, in 2008-2016. They identified more than 1 million opioid-naive patients who had surgery, 56% of whom were prescribed opioids afterwards.
During follow-up, which lasted a median of 2.67 years, the researchers identified a code for abuse in 0.6% of these patients, or 183 per 100,000 person-years.
Among patients not given a refill, the rate of misuse was 145 per 100,000, compared to 293 per 100,000 for those who received a single refill.
Misuse risk increased by 44% for each additional refill, after adjustment (P<0.001). The adjusted risk associated with each additional week of opioid use was 19.9% (P<0.001).
Dosage also predicted misuse, with the risk increasing by 0.8% for every additional morphine mg equivalent (MME)/day a person was prescribed. However, the researchers found, even doses of above 150 MME/day were associated with minimal misuse risk as long as treatment duration was short.
The results give clinicians tools to help explain the risks of long-term opioid treatment to their patients, Dr. Brat noted in a telephone interview with Reuters Health.
“Our data suggest that the dose is much less important than the amount of time a patient spends taking an opioid,” he added. “At best, it suggests there should be flexibility in the way that people are prescribed opiates immediately after surgery.”
Many surgeons got the message that they needed to reduce the opioid doses they prescribed, but in some cases this meant a patient stayed on the drug for a longer time, Dr. Brat pointed out. “Our data suggest that being slightly more flexible with that initial dose is less important than making sure those patients are weaned off opiates as quickly as possible.”
Dr. Martin A. Makary of Johns Hopkins School of Medicine in Baltimore coauthored an editorial on the role of overprescribing in the opioid crisis published in the same journal late last year. “We haven’t traditionally thought of long-term dependency as a complication of routine use, and this study further supports the growing notion that it is an important consideration,” he told Reuters Health in a telephone interview.
“We haven’t had good guidelines on what an average narcotic-naive adult should be prescribed when they leave the hospital after surgery,” he added.
To address the issue, Dr. Makary and colleagues at Johns Hopkins’ Center for Opioid Research and Education recently released a list of best practice guidelines for prescribing after 10 common surgeries (http://bit.ly/2Dz9mzi).
“We embrace variation, but we provide a range and a ceiling for what that initial opioid prescription should be,” he said. “The reality is healthcare is messy, and many times aids like this can be helpful.”
SOURCES: http://bit.ly/2DGvF5C and http://bit.ly/2DC66n1
BMJ 2018.
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