Emerging evidence suggests opioid addiction starts within weeks of the first script
Shorter prescriptions for opioid initiation could be the key to reducing long-term opioid use, a major health protection agency suggests.
In their recent Morbidity and Mortality Weekly Report, the US Centers for Disease Control found that among opioid-naïve, cancer-free adults, each additional day they were prescribed opioids increased the risk of long-term use.
For patients prescribed opioids for only one day, the risk of continued opioid use a year later was 6%. But if the initial prescription was eight days or more, the risk jumped to 13.5%.
Victorian RACGP chair Dr Cameron Loy said the information emerging over the last few years should make clinicians increasingly concerned about opioids in general practice.
The CDC finding that roughly three in 10 patients who were given a one-month supply would still be on opioids a year later “should cause us all to pause”, he said.
Moreover, the report found one in seven patients given a second script or refill were on opioids a year later.
“Treatment of acute pain with opioids should be for the shortest duration possible,” the authors wrote. “When initiating opioids, caution should be exercised when prescribing >1 week of opioids or when authorising a refill or a second opioid perception because these actions approximately double the chances of use one year later.”
“The opioid crisis in the US is very real and it is having a marked impact, particularly on middle America,” Dr Loy said.
These patterns are being echoed in Australia, with a delay of a few years.
“We as GPs should pay very close attention to what is happening in the United States so that it is not repeated to its full extent here in Australia,” he said.
“To pay attention means that we will actually save Australian lives.”
The researchers evaluated the use of almost 1.3 million incident opioid users at 12 months and 36 months after the initial prescription.
“As expected, patients initiated on long-acting opioids had the highest probabilities of long-term use,” they wrote.
“However, the finding that patients initiated with tramadol had the next highest probability of long-term use was unexpected.”
Despite initially being thought a relatively safe opioid agonist, research was emerging that tramadol was a growing danger for long-term use and adverse events.
The opioid crisis in the US is very real and it is having a marked impact.
It was important to really question why the prescription was being started in the first place, Dr Loy said.
Good prescribing boundaries included explaining to the patient that they were “starting to stop”, he said.
“And it is important to stop,” he said.
“This data reinforces that message [that] we are placing our patients at risk of ongoing opiate use to a year the longer we prescribe them in that first month.”
Other strategies include specifying the exact number of pills for the pharmacist to dispense, rather than allowing a patient to take an entire box.
Dr Loy said it was a shame that real-time monitoring systems had not been rolled out across all the states, but noted that coroners had shown that 70% of opiate overdose deaths had a single prescriber.
Regardless, overdose was only one of the markers of the chaos opiates could produce in someone’s life, he said.
MMWR 2017; online 17 March