A new study from Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School (HMS) sheds light on the link between physicians’ opioid prescription patterns and subsequent abuse.
Among surgery patients with no history of recent or chronic opioid use, the researchers demonstrated that duration of treatment is a more potent predictor of abuse and overdose than dosage.
Most clinical efforts have focused on minimizing risk through dosage management. The study appears in The BMJ (formerly The British Medical Journal) and suggests current efforts to mitigate opioid addiction are misguided.
However, dosage — the amount of medication a patient takes over 24 hours — does emerge as a powerful risk indicator among those who took the medications for extended periods.
The findings highlight the need for prescribing physicians to pay particular attention to the duration of treatment and the number of refills. Moreover, researchers suggest that surgeons should be swift to refer patients to chronic pain specialists for symptom management if their discomfort persists.
“As surgeons, we often struggle to balance the risk of abuse with our duty to manage pain, but our findings underscore how potent a single stroke of the pen can be in fueling this risk,” said study co-first author Gabriel Brat, M.D., a trauma surgeon at BIDMC.
Researchers believe the new findings will provide much-needed insight into the complex and nuanced dynamics that may fuel opioid misuse; specifically, the results could help inform field-specific guidelines for surgeons.
Surgeons rely on opioid pain management more than any other specialty; research shows that surgery patients are four times more likely than other patients to be treated with opioids.
“We are in the midst of an epidemic, and physician prescription practices play no small part in it,” said senior investigator Nathan Palmer, Ph.D., a biomedical informatics researcher at HMS.
“Understanding differences in risk for opioid misuse across various patient populations and clinical contexts is critical in informing the creation of narrowly tailored guidelines, clinical decision making, and the national conversation on this topic.”
“Our results indicate that each additional week of medication use, every refill is an important maker of risk for abuse or dependence,” said co-first author Denis Agniel, Ph.D., a statistician at the RAND Corporation and a part-time lecturer in the Department of Biomedical Informatics at HMS.
In the new study, none of the 560,000 patients had a record of chronic or extended opioid use leading up to surgery.
For the purposes of the research, patients were deemed non-opioid users if they had not taken opioids in the two months prior to their surgery, or if they had used opioids for fewer than seven days prior to their procedure.
Of the more than half million patients, 0.6 percent, or 5,906, developed dependence, demonstrated symptoms of abuse, or experienced a nonfatal overdose — collectively defined as opioid misuse. A third of the misuse diagnoses occurred within a year of the surgery.
Each additional week of opioid use increased the risk of dependence, abuse, or overdose by 20 percent. Each additional refill boosted the risk by 44 percent, the analysis showed, with the first refill more than doubling the risk.
By contrast, dosage played a far smaller role, the analysis showed. In fact, the researchers noted, among people taking opioids for short periods (two weeks or less) the risk for misuse was no greater even among patients on dosages that were twice as high.
However, higher dosage did propel risk significantly among those taking opioids for nine weeks or longer, a finding that suggests a potent confluence of duration and dosage among long-term users, the team said.
Current guidelines on opioid pain management do not address specific patient populations. The new findings, however, suggest that clinical context matters, and that opioid decision making should vary with the context.
“As physicians, we face a dilemma with each opioid prescription, so we need a more nuanced understanding of how to weigh the risks and benefits of opioid pain management immediately after surgery, including factors that influence misuse,” said Isaac Kohane, M.D., Ph.D., co-senior author on the study.
“These results provide much-needed clarity.”