Mayo Clinic: 21% of Patients on Opioids Extend Use Past Three Months
Thursday, July 9, 2015 | 3546 | 0 | 0 min read
As groups that draft medical treatment guidelines push harder against the use of long-term opioid therapy, a study from the Mayo Clinic has suggested that nearly one-quarter of patients using the drugs continue receiving prescriptions after three months — and some of the people most likely to be on a chronic opioid regimen are those that guidelines specifically say should not have them.
The study, published in the July issue of the Mayo Clinic Proceedings, examined what the authors acknowledged was a relatively small sample size of 293 patients using opioid prescriptions in Olmsted County, Minnesota. The study found that 21% who received an opioid prescription were still using opioids after three months — at which point it defined the patient as being an “episodic” opioid user.
Small as the study may be, it comes as national momentum in the workers’ compensation medical arena builds against long-term or “chronic” use of opioids to treat pain. The Washington State Interagency Guidelines on Prescribing Opioids for Pain, a nationally influential document, was updated in June to declare that doctors should seek to avoid chronic opioid analgesic therapy — lasting longer than three months — if at all possible. On top of the risk of addiction and overdose, the guidelines state that opioids have reduced efficacy when used long-term and that 60% of patients who receive opioids longer than three months are still using the drugs after five years.
Minnesota’s Department of Labor and Industry adopted opioid guidelines similar to Washington’s on Monday. The guidelines go into effect on Saturday.
Mark Pew, senior vice president of the medical cost containment firm Prium, said 21% may be a low number if the study had looked only at workers’ compensation patients.
“Certainly there are some that say that creates an entitlement-type mentality, creates a passive rather than an active approach to their return to function, and therefore can increase their reliance on drugs,” Pew said during an interview.
Pew said he and others in the workers' compensation medical management field have thought for some time that the percentage of patients moving from short-term to long-term opioid therapy is substantial. He said the study helps illustrate the importance of physicians evaluating patients more closely before writing even one prescription for opioids.
“One thing I've noticed in those initial progress reports from doctors, they don't ask those questions, and that's a big problem,” Pew said.
The Mayo Clinic study noted the importance of patient selection as well — not only because certain risk factors are associated with higher rates of addiction and overdose, but because those same risk factors also make a person more likely to become a long-term opioid user. Nicotine users were 78% more likely than those who didn’t use nicotine to take opioids for longer than three months, and more than twice as likely as to take opioids for four months or longer.
Even more pronounced was long-term opioid use among patients with a history of substance abuse. Patients identified as having a history of abusing alcohol, benzodiazepines, marijuana, methamphetamines or cocaine were more than eight times as likely as those without a history of substance abuse to take opioids for four months or longer.
The Washington guidelines, as well as the American Pain Society’s guidelines on prescribing opioids for long-term therapy adopted in 2009, identify substance abuse as a red flag for addiction and overdose that doctors should look for before offering the drugs. The Mayo Clinic study shows that patients who are most likely to take opioids long-term are often the same patients that guidelines caution doctors not to prescribe the drugs to.
Steven Moskowitz, senior medical director for Paradigm Outcomes, said the combination of risk factors with a higher likelihood of long-term use creates a kind of vicious circle — the patients most at risk for overdose are more likely to take opioids long-term, and being on long-term opioids increases the chances of overdose. The study also noted that while nicotine is associated with greater use of opioids, use of opioids appears to drive up nicotine use.
“It's that first prescription that starts the trajectory,” Moskowitz said.
However, he said doctors often don’t think to take into consideration whether the patient smokes when deciding whether to prescribe opioids.
“A lot of times in doctor's notes you see that they're a smoker but they don't necessarily look at that as a risk factor,” he said.
Moskowitz said one reason for those vicious circles might be the simple bond between a doctor and a patient—if a patient says they’re in pain, a physician will tend to want to help.
“Doctors' response to patients' requests, you know, they want to please them. If they say they have pain, they will want to prescribe them something,” he said.