Addiction Risks Rise after Day Three of an Opioid Prescription

A new study shows that the length of an initial opioid prescription influences the risks of long-term use.

Prescribing patterns for opioids have long been thought to be linked to increased risks of continued use and addiction. The new study confirms that these risks rise sharply in the first few days of use. The likelihood of a patient using opioids one and three years later increases after the third day of an initial prescription, and rises sharply after the fifth day-a finding that surprised the researchers. Long-acting opioids, followed by tramadol, had the highest probability of being used one and three years after the initial prescription.

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Anuj Shah“We all anticipated that the longer the prescription, the higher the likelihood of long-term use. But the rapidity and how early on in the prescribing cycle this happened was something we did not expect,” said Anuj Shah, BPharm, a PhD student and Graduate Research Assistant  at the University of Arkansas for Medical Sciences (UAMS) in Little Rock. Shah is lead author of the study, published in Morbidity and Mortality Weekly Report. “Just going from a five-day supply to a ten-day supply increases the chances of long-term opioid use almost two-fold.”

These findings indicate that an initial opioid prescription of three days or fewer can reduce the chances of long-term opioid use, and that long-acting opioids must be prescribed with more care. “Our goal with this study is just to inform both prescribers and pharmacists that your thought process on opioid prescribing or opioid dispensing needs to be really careful, because the chances that patients get addicted or continue these medications long term rises so very rapidly so very early on in the process,” said Shah.

“If you look at the statistics, if you are at three days of use, [likelihood of long-term use] is about 6% or 7%; at four days it goes up to almost 8%. Once you hit one week of use, you are almost at 12% to 14%,” Shah said. “So it almost doubles from  a prescription of less than three days.”

For someone who is given an 11-day supply of a first opioid, the probability of that person still being an opioid user one year later is 25%, said Bradley Martin, PharmD, Professor and Head of the Division of Pharmaceutical Evaluation and Policy at UAMS College of Pharmacy.  “I suspect most clinicians, including pharmacists, had a sense of the risk, but probably did not appreciate how rapidly the risk of long-term opioid use increases,” said Martin.

The study did not look at safety, but rather at the risk of continued use one and three years after an initial prescription, he added. “Some long-term use is reasonably safe, while some would pose risk depending on the individual and the goals of treatment.”

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The study is based on data from a random sample of patient records from IMS Lifelink+, a database of commercial health plan information.  The records are those of patients who had at least one opioid prescription between 2006 and 2015, but who had not had one for at least six months previously, did not have cancer, and had not been diagnosed with a substance-abuse problem. Information on opioid use one and three years after that initial prescription was also evaluated. The opioids included oxycodone, hydrocodone, and tramadol.

About 1 in 17 patients was found to be on an opioid one year after the initial prescription, no matter what type of opioid or length of prescription. The likelihood of chronic opioid use rose for every added day of medication starting on day three, and increased sharply from day 6 through day 31. The likelihood of chronic opioid use also went up sharply if a second prescription was written or refilled.

The study also found a higher risk of chronic opioid use one and three years later with long-acting opioids or tramadol, a drug thought to have a lower risk of addiction. These patients were more likely to remain on opioids than those prescribed hydrocodone or oxycodone-another surprising finding according to Shah. This pattern may be due to the preference of prescribers for a drug they consider safer for long-term use. So it isn’t the drug that increases the risk so much as the longer prescriptions used with it, he said.