What Causes More Opioid Misuse: Higher Doses or Longer Durations?

This article was collaboratively written with Zil-e-Huma Sabir, a fourth-year PharmD candidate at Chicago State University College of Pharmacy.

The opioid epidemic continues to be a serious problem in the United States since it began in the early 2000s, and has resulted in the tripling of drug overdose deaths.^1,2 Drug overdose is now ranked as the leading cause of death related to unintentional injury. According to the CDC, more than 47,000 drug overdose deaths occurred in 2014 alone, and approximately 60% involved an opioid. Overdoses from prescription opioids have increased by more than 50% over the past 10 years.

Opioid analgesics, while important for the treatment of pain, are associated with high rates of misuse.³ The majority of patients that overdose on prescription opioids are identified as non-chronic opioid users, which corresponds to patients using opioids for less than 90 days. Finding the right balance of appropriateness for opioid utilization has been difficult, as 3-10% of opioid naive patients tend to become chronic users.

It is known that recurrent administration of opioids can result in physical dependence, however, the paucity of clear clinical guidance on misuse avoidance has led to disparities in clinical consensus.⁴ As a result, prescribers are at an impasse about whether, when, and how much opioid to prescribe for pain without putting patients at risk for development of misuse. Several studies suggest that higher opioid doses within standards of clinical practice increase mu opioid receptor saturation and that under-treatment of acute pain increases the risk of drug seeking behavior, chronic pain, and possible overdose.⁵ Therefore, the clinical question is whether the dose or duration of opioid use matters more to prevent its misuse.

Similar to the current CDC guidelines, Bateman and Choudhry advocated that prescribing of opioids for acute pain should be restricted to 3 days and rarely should exceed 7 days.^6,7 The authors stated that limiting the duration of opioids prescribed could lower the risk of opioid misuse and that restricting the duration would promote safer use as it reduces the exposure of opioid naive patients to addictive behaviors. They acknowledged that there may be certain conditions, for example, major surgery, trauma, or severe burns that may require opioid prescribing beyond the recommended duration.

The most recent study comparing dose versus duration was a retrospective cohort study evaluating the association between opioid prescription refills after surgery and misuse in opioid naive patients between 2008 and 2016.⁵ The patient population included those who were commercially insured, opioid naive, and undergoing surgery. The study focused on early and appropriate treatment of pain, even if it required higher initial doses of opioids for a shorter duration of time. The study found that for every week of additional opioid use, a patient’s risk of misuse increased by 19.9%. This suggests that the duration of opioid use rather than dosage, whether low or high intensity, is strongly associated with opioid misuse in post-surgical patients.

Despite the literature present, there is no consensus on whether opioid dose or duration leads to its misuse. Therefore, while prescribing, clinicians should consider patient specific characteristics such as age, history of substance abuse (mainly with alcohol, benzodiazepines, or opioids), underlying disease states, history of long-term opioid use, and the patient’s pain severity. Assessing the actual need for prescribing opioids is crucial, as non-opioid based pain relievers can be utilized in a large percentage of patients. However, if opioids are a necessary for a patient, then they should be educated regarding misuse. Clinicians should refer to the current CDC practice guidelines that recommend prescribing opioids at lower doses for a shorter duration of time, as well as weigh the overall risks and benefits of prescribing opioids.⁷

References:

• Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths--United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64:1378-82.

• Elzey MJ, Barden SM, Edwards ES. Patient Characteristics and Outcomes in Unintentional, Non-fatal Prescription Opioid Overdoses: A Systematic Review. Pain Physician. 2016;19(4):215-28.

• Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR. Characteristics of opioid prescriptions in 2009. JAMA. 2011;305(13):1299-1301.

• Volkow ND, McLellan AT. Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies. N Engl J Med. 2016;374(13):1253-63.

5. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study BMJ. 2018; 360 :j5790

• Bateman BT, Choudhry NK. Limiting the Duration of Opioid Prescriptions Balancing Excessive Prescribing and the Effective Treatment of Pain. JAMA Intern Med. 2016;176(5):583—584.

7. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(1):1—49.