FDA highlights risks associated with long-term opioid use.

We describe age and gender trends in long-term use of prescribed opioids for chronic noncancer pain in 2 large health plans. Age- and gender-standardized incident (beginning in each year) and prevalent (ongoing) opioid use episodes were estimated with automated health care data from 1997 to 2005. Profiles of opioid use in 2005 by age and gender were also compared. From 1997 to 2005, age-gender groups exhibited a total percentage increase ranging from 16% to 87% for incident long-term opioid use and from 61% to 135% for prevalent long-term opioid use. Women had higher opioid use than did men. Older women had the highest prevalence of long-term opioid use (8%-9% in 2005). Concurrent use of sedative-hypnotic drugs and opioids was common, particularly among women. Risks and benefits of long-term opioid use are poorly understood, particularly among older adults. Increased surveillance of the safety of long-term opioid use is needed in community practice settings.

Clinical guidelines recommend that providers risk-stratify patients with cancer before prescribing opioids. Prior research has demonstrated that a simple cancer opioid risk score might help identify to patients with cancer at the time of diagnosis with a high likelihood of long-term posttreatment opioid use. This current project validates this cancer opioid risk score in a generalizable, population-based cohort of elderly cancer survivors. This study identified 44,932 Medicare beneficiaries with cancer who had received local therapy. Longitudinal opioid use was ascertained from Medicare Part D data. A risk score was calculated for each patient, and patients were categorized into low-, moderate-, and high-risk groups on the basis of the predicted probability of persistent opioid use. Model discrimination was assessed with receiver operating characteristic curves. In the study cohort, 5.2% of the patients were chronic opioid users 1 to 2years after the initiation of cancer treatment. The majority of the patients (64%) were at low risk and had a 1.2% probability of long-term opioid use. Moderate-risk patients (33% of the cohort) had a 5.6% probability of long-term opioid use. High-risk patients (3.5% of the cohort) had a 75% probability of long-term opioid use. The opioid risk score had an area under the receiver operating characteristic curve of 0.869. This study found that a cancer opioid risk score could accurately identify individuals with a high likelihood of long-term opioid use in a large, generalizable cohort of cancer survivors. Future research should focus on the implementation of these scores into clinical practice and how this could affect prescriber behavior and patient outcomes. A novel 5-question clinical decision tool allows physicians treating patients with cancer to accurately predict which patients will persistently be using opioid medications after completing therapy.

Opioid analgesics may be initiated following surgical and medical hospitalization or in ambulatory settings; rates of subsequent long-term opioid (LTO) use have not been directly compared. This retrospective cohort study of the Veterans Health Administration (VHA) included all patients receiving a new outpatient opioid prescription from a VHA provider in fiscal year 2011. If a new outpatient prescription was filled within 2 days following hospital discharge, the initiation was considered a discharge prescription. LTO use was defined as an episode of continuous opioid supply lasting a minimum of 90 days and beginning within 30 days of the initial prescription. We performed bivariate and multivariate analyses to identify the factors associated with LTO use following surgical and medical discharges. Following incident prescription, 5.3% of discharged surgical patients, 15.2% of discharged medical patients, and 19.3% of outpatient opioid initiators received opioids long term. Medical and surgical patients differed; surgical patients were more likely to receive shorter prescription durations. Predictors of LTO use were similar in medical and surgical patients; the most robust predictor in both groups was the number of days' supply of the initial prescription (odds ratio [OR] = 1.24 and 95% confidence interval [CI], 1.12-1.37 for 8-14 days; OR = 1.56 and 95% CI, 1.39-1.76 for 15-29 days; and OR = 2.59 and 95% CI, 2.35-2.86 for >30 days) compared with the reference group receiving =7days. Rates of subsequent LTO use are higher among discharged medical patients than among surgical patients. Characteristics of opioid prescribing within the initial 30 days, including initial dose and days prescribed, were strongly associated with LTO use.

The aim of this study was to identify associations between early care decisions and long-term opioid (LTO) use in opioid-naïve patients with a new physician consultation for low back pain (LBP) at which an opioid was prescribed. A retrospective study of claims data was used to identify opioid-naïve LBP patients who were prescribed opioids at the index physician visit. Early care variables captured included additional nonopioid medications prescribed within 14 days and provider visits or diagnostic imaging within 30 days of the index visit. A multivariate logistic model was used to identify early care variables associated with the outcome of (LTO) use in the year following the index visit controlling for patient factors. A total of 707 patients were included in this study. The mean age was 38.1 (±11.6), and 67.8% were female individuals and 76.9% were Medicaid beneficiaries. Early care medications were muscle relaxants (32.2%), nonsteroidal anti-inflammatories (29.3%), oral steroids (11.7%), and benzodiazepines (8.3%). The most common early care provider visits were with primary care (31.0%) and physical therapy (13.0%). A total of 172 patients (24.3%) progressed to LTO use. Controlling for patient factors, early care variables increasing risk for LTO use were an early benzodiazepine prescription and primary care visit. An early physical therapy visit was associated with reduced risk for LTO use. Early care decisions were predictive of LTO use following a new LBP consultation at which opioids were prescribed. Our results support recommendations to avoid concurrent benzodiazepine prescribing and to consider other evidence-based pain treatments such as physical therapy early, particularly for patients at high risk for LTO use or misuse.

Chronic preoperative opioid use is a risk factor for increased complications, resource use, and costs after cervical fusion

Improved understanding of temporal trends in short- and long-term opioid prescribing may inform efforts to curb the opioid epidemic. To characterize the prevalence of short- and long-term opioid prescribing in the Veterans Health Administration (VHA) from 2010 to 2016. Observational cohort study using VHA databases. All patients receiving at least one outpatient prescription through the VHA during calendar years 2010 through 2016. Prevalence of opioid use from 2010 through 2016, stratified by short-term, intermediate-term, and long-term use. Temporal trends in discontinuation among existing long-term users and initiation of new long-term use and the net impact on rates of long-term opioid use. Relative likelihood of transitioning to long-term opioid use contrasted with use patterns in the prior year. The prevalence of opioid prescribing was 20.8% in 2010, peaked at 21.2% in 2012, and declined annually to 16.1% in 2016. Between 2010 and 2016, reductions in long-term opioid prescribing accounted for 83% of the overall decline in opioid prescription fills. Comparing data from 2010-2011 to data from 2015-2016, declining rates in new long-term use accounted for more than 90% of the decreasing prevalence of long-term opioid use in the VHA, whereas increases in cessation among existing long-term users accounted for less than 10%. The relative risk of transitioning to long-term use during 2016 was 6.5 (95% CI: 6.4, 6.7) among short-term users and 35.5 (95% CI: 34.8, 36.3) among intermediate users, relative to patients with no opioid prescriptions filled during 2015. Opioid prescribing trends followed similar trajectories in VHA and non-VHA settings, peaking around 2012 and subsequently declining. However, changes in long-term opioid prescribing accounted for most of the decline in the VHA. Recent VA opioid initiatives may be preventing patients from initiating long-term use. This may offer valuable lessons generalizable to other healthcare systems.

Objectives: The objective of this study was to estimate the extent to which differences in person-level characteristics between opioid users and nonusers contribute to poor health-related quality of life (HRQoL) of long-term opioid users with chronic noncancer pain condition (CNCP). Materials and Methods: We conducted a retrospective cohort study of adults (n=5917) using longitudinal data from multiple years of Medical Expenditure Panel Survey. Adults with CNCP were classified into short-term, long-term, and opioid nonusers. We measured HRQoL with physical component summary (PCS) and mental component summary (MCS) scores from the Short-Form 12 Questionnaire. A regression decomposition analysis of results from linear regression was performed. Results: Among adults with CNCP, 17.8% and 17.2% reported long-term and short-term opioid use, respectively. Long-term opioid users had lower PCS scores (β=−4.48; P<0.001) as compared with nonusers, even after adjusting for other independent variables. There were no statistically significant associations of long-term opioid use to MCS and short-term opioid use to both PCS and MCS scores. Postlinear regression decomposition analyses revealed that 44.8% of the difference in PCS scores (−3.76 of −8.41) was explained by differences in employment, physical activity, number of CNCP, and other chronic conditions, and use of nonopioid pain medications between long-term opioid users and nonusers. Conclusions: Long-term opioid use was associated with lower HRQoL. The difference in HRQoL between long-term opioid users and nonusers was explained by both modifiable and nonmodifiable patient characteristics. Our findings suggest that improving HRQoL among long-term opioid users may require interventions and policies both within and beyond health care.

The prevalence of chronic pain is high in patients with rheumatoid arthritis (RA), increasing the risk for opioid use. The objective of this study was to assess disease-modifying antirheumatic drug (DMARD) use and its effect on long-term opioid use in patients with RA. This cohort study included Medicare beneficiaries with diagnosis of RA who received at least 30-day consecutive prescription of opioids in 2017 (n = 23,608). The patients were grouped into non-DMARD and DMARD users, who were further subdivided into regimens set forth by the American College of Rheumatology. The outcome measured was long-term opioid use in 2018 defined as at least 90-day consecutive prescription of opioids. Dose and duration of opioid use were also assessed. A multivariable model identifying factors associated with non-DMARD use was also performed. Compared with non-DMARD users, the odds of long-term opioid use were significantly lower among DMARD users (odds ratio, 0.89; 95% confidence interval, 0.83-0.95). All regimens except non-tumor necrosis factor biologic + methotrexate were associated with lower odds of long-term opioid use relative to non-DMARD users. The mean total morphine milligram equivalent, morphine milligram equivalent per day, and total days of opioid use were lower among DMARD users compared with non-DMARD users. Older age, male sex, Black race, psychiatric and medical comorbidities, and not being seen by a rheumatologist were significantly associated with non-DMARD use. Disease-modifying antirheumatic drug use was associated with lower odds of long-term opioid use among RA patients with baseline opioid prescription. Factors associated with non-DMARD use represent a window of opportunity for intervention to improve pain-related quality of life in patients living with RA.

Sustained postoperative opioid use after elective surgery is a matter of growing concern. Herein, the authors investigated incidence and predictors of long-term opioid use among patients undergoing elective lumbar spine surgery, especially as a function of opioid prescribing practices at postoperative discharge (dose in morphine milligram equivalents [MMEs] and type of opioid). The OptumLabs Data Warehouse (OLDW) was queried for postdischarge opioid prescriptions for patients undergoing elective lumbar decompression and discectomy (LDD) or posterior lumbar fusion (PLF) for degenerative spine disease. Only patients who received an opioid prescription at postoperative discharge and those who had a minimum of 180 days of insurance coverage prior to surgery and 180 days after surgery were included. Opioid-naive patients were defined as those who had no opioid fills in 180 days prior to surgery. The following patterns of long-term postoperative use were investigated: additional fills (at least one opioid fill 90-180 days after surgery), persistent fills (any span of opioid use starting in the 180 days after surgery and lasting at least 90 days), and Consortium to Study Opioid Risks and Trends (CONSORT) criteria for persistent use (episodes of opioid prescribing lasting longer than 90 days and 120 or more total days' supply or 10 or more prescriptions in 180 days after the index fill). Multivariable logistic regression was performed to identify predictors of long-term use. A total of 25,587 patients were included, of whom 52.7% underwent PLF (n = 13,486) and 32.5% (n = 8312) were opioid-naive prior to surgery. The rates of additional fills, persistent fills, and CONSORT use were 47%, 30%, and 23%, respectively, after PLF and 35.4%, 19%, and 14.2%, respectively, after LDD. The rates among opioid-naive patients were 18.9%, 5.6%, and 2.5% respectively, after PLF and 13.3%, 2.0%, and 0.8%, respectively, after LDD. Using multivariable logistic regression, the following were identified to be significantly associated with higher risk of long-term opioid use following PLF: discharge opioid prescription ≥ 500 MMEs, prescription of a long-acting opioid, female sex, multilevel surgery, and comorbidities such as depression and drug abuse (all p < 0.05). Elderly (age ≥ 65 years) and opioid-naive patients were found to be at lower risk (all p < 0.05). Similar results were obtained on analysis for LDD with the following significant additional risk factors identified: discharge opioid prescription ≥ 400 MMEs, prescription of tramadol alone at discharge, and inpatient surgery (all p < 0.05). In an analysis of pharmacy claims from a national insurance database, the authors identified incidence and predictors of long-term opioid use after elective lumbar spine surgery.

PurposeDenmark has a high consumption of prescribed opioids, and many citizens with chronic non-cancer pain (CNCP). Therefore, we aimed to characterize and assess epidemiological risk factors associated with long-term non-cancer opioid use among Danish citizens.Patients and MethodsWe conducted a longitudinal, retrospective, observational, register-based study using nationwide databases containing essential medical, healthcare, and socio-economic information. Statistical analysis, including backward stepwise logistic regression analysis, was used to explain long-term opioid use by individuals filling at least one prescription for an opioid product N02AA01–N02AX06 during 01/01/2004–31/12/2017, follow-up until the end of 2018.ResultsThe analyzed cohort contained N=1,683,713 non-cancer opioid users, of which 979,666 were classified with CNCP diagnosis using ICD-10 codes. Long-term opioid use was predicted by a mean of 1,583.30 and a median of 300 oral morphine equivalent mg (OMEQ) per day during the first year, together with divorced, age group 40–53 years, retirement, receiving social welfare or unemployment ≥6 months. In addition, living in Northern Jutland, co-medications such as beta-blockers, anti-diabetics, anti-rheumatics, and minor surgery ≤90 days before inclusion. Protective variables were an education level of secondary school or higher, children living at home, household income of middle or highest tertile, opioid doses in either the 2nd or 3rd quartile OMEQ, male, the oldest age group, living in the Capital Region or Zealand, co-medication lipid-lowering, one comorbidity, heart failure, surgeries ≤90 days before the index: lips/teeth/jaw/mouth/throat, heart/vessels, elbow/forearm, hip/thigh, knee/lower leg/ankle/foot.ConclusionLong-term opioid users differ epidemiologically from those using opioids for a shorter period. The study findings are essential for future recommendations revision in Denmark and comparable countries.

To describe the most common side effects associated with the use of opioid treatment in patients with moderate to severe cancer pain; to discuss research findings specific to the use of opioids for cancer pain in long-term cancer survivors. Published research, articles from a literature review, and U. S. statistics. Side effects associated with opioid use are a major contributor to patient reluctance to follow treatment plans for cancer pain. Clinicians must follow the critical steps necessary to build comprehensive treatment plans that include a preventive approach to side effects and opioid rotation when side effects do not resolve. Side effects associated with long-term use of opioids by cancer survivors are a major contributor to patient reluctance to follow a cancer pain treatment plan. Patient education efforts must promote open and clear communication between survivors and their providers about side effects and other important issues related to long-term use of opioids in managing pain related to cancer and its treatment. Oncology nurses recognize that patients often require the long-term use of opioids when they experience chronic pain as a result of their disease or its treatment. The long-term physical and cognitive effects of such opioid use are not well known, despite the advances that have been made in cancer pain control and research. Survivors should communicate their concerns about side effects to the treatment team. In addition, patients and family members must be encouraged to inform their providers about personal attitudes, beliefs, and practices that may affect decisions about taking their analgesics as prescribed. Most importantly, oncology nurses must teach patients and their families to self-advocate for optimal pain relief with minimal side effects.

IntroductionWe aimed to investigate the proportion and associated factors for new long-term opioid use and its long-term effects after lung cancer surgery.MethodsThe South Korean National Health Insurance Database was used...

State policies to optimize prescriber use of Prescription Drug Monitoring Programs (PDMPs) have proliferated in recent years. Prominent policies include comprehensive mandates for prescriber use of PDMP, laws allowing delegation of PDMP access to office staff, and interstate PDMP data sharing. Evidence is limited regarding the effects of these policies on adverse opioid-related hospital events. The objective of this study was to assess the effects of 3 PDMP policies on adverse opioid-related hospital events among patients with prescription opioid use. We examined 2011-2015 data from a large national commercial insurance database of privately insured and Medicare Advantage patients from 28 states with fully operating PDMPs by the end of 2010. We used a difference-in-differences framework to assess the probabilities of opioid-related hospital events and association with the implementation of PDMP policies. The analysis was conducted for adult patients with any prescription opioid use, a subsample of patients with long-term prescription opioid use, and stratified by older (65+) versus younger patients. Comprehensive use mandates were associated with a relative reduction in the probability of opioid-related hospital events by 28% among patients with any opioid and 21% among patients with long-term opioid use. Such reduction was greater (in relative terms) among older patients despite the lower rate of these events among older than younger patients. Delegate laws and interstate data sharing were associated with limited change in the outcome. Comprehensive PDMP use mandates were associated with meaningful reductions in opioid-related hospital events among privately insured and Medicare Advantage adults with prescription opioid use.

Prolonged opioid use is common following traumatic injuries. Although preventive strategies have been recommended, the evidence supporting their use is low. The objectives of this study were to select interdisciplinary strategies to prevent long-term, detrimental opioid use in trauma patients for further evaluation and to identify implementation considerations. A consensus study using the nominal group technique. Four trauma systems in Canada. Participants included expert clinicians and decision makers, and people with lived experience. Participants had to discuss the relevance and implementation of 15 strategies and then rank them using a 7-point Likert scale. Implementation considerations were identified through a synthesis of discussions. A total of 41 expert stakeholders formed the nominal groups. Overall, eight strategies were favored: 1) using multimodal approach for pain management, 2) professional follow-up in physical health, 3) assessment of risk factors for opioid misuse, 4) physical stimulation, 5) downward adjustment of opioids based on patient recovery, 6) educational intervention for patients, 7) training offered to professionals on how to prescribe opioids, and 8) optimizing communication between professionals working in different settings. Discussions with expert stakeholders revealed the rationale for the selected strategies and identified issues to consider when implementing them. This stakeholder consensus study identified, for further scientific study, a set of interdisciplinary strategies to promote appropriate opioid use following traumatic injuries. These strategies could ultimately decrease the burden associated with long-term opioid use.

An Opioid Prescription for Men Undergoing Minor Urologic Surgery Is Associated with an Increased Risk of New Persistent Opioid Use