How Many Days of Opioids Do Primary Care Patients With Acute Pain Need?

In 2017, opioids were involved in 47,600 U.S. deaths, about a third of them involving a prescription opioid. Concern that overprescribing for acute pain fuels misuse, diversion and overdose led several states to limit opioid prescriptions. To see what patients actually needed before those limits spread, researchers from the Food and Drug Administration and academic partners analyzed 2014 claims from a large nationwide commercial insurer.

Who was studied

The researchers looked at adults whose first primary care visit for one of ten common acute pain conditions was followed within 7 days by an opioid prescription:

• back pain with or without radiculopathy (nerve involvement);
• neck pain, joint pain, and tendon or bursa pain;
• muscle strains and sprains, and musculoskeletal injuries such as ligament tears;
• kidney stones (urinary calculus);
• headache; and
• dental pain.

They excluded people with recent opioid use, substance abuse, cancer, hospice or hospital stays, or surgery in the previous six months, and people given 30 days or more or opioid patches, on the assumption that long-term therapy was intended. The key measure was a refill: any further oral opioid fill in the 30 days after the first, taken as a sign that the first supply had not been enough.

Findings

• Of 176,607 patients seen for acute pain, 13,440 (7.6%) filled an opioid prescription within a week — from 3.5% for headache to 27.6% for dental pain.
• The median first fill was 4 to 7 days' supply, 20 to 30 pills, and 100 to 155 morphine milligram equivalents.
• Only 2,392 (17.8%) of those who filled a prescription got a refill within 30 days — about 1% of the whole group. Unadjusted refill rates were higher among men (19.3%) than women (15.8%), and among people who had recently used benzodiazepines (26.5%), sedative hypnotics (20.0%) or gabapentin (28.3%).
• For some conditions, such as back pain with radiculopathy, kidney stones and dental pain, the chance of a refill fell as the first prescription got longer; for others, such as joint pain and back pain without radiculopathy, it stayed about the same.
• After a 7-day first prescription, the adjusted probability of a refill was under 25% for nine of the ten conditions, ranging from 11% for headache to 41% for musculoskeletal injury.

What it means

The median first prescription lasted 4 to 7 days, and fewer than one in five patients needed more, suggesting that such a supply was usually enough — and sometimes more than enough — consistent with CDC's 2016 guideline on prescribing opioids. A 7-day supply might even risk overtreating some conditions. But the variation between conditions, and between patients, shows that recovery times differ, as do clinicians' practices and access to non-opioid treatments. Because legal limits apply regardless, the authors conclude, health systems need efficient ways to provide refills when they are clinically appropriate, along with access to non-opioid therapies.

Limitations

• The data predate many prescribing limits, and more recent patterns may differ because of state, health system and other policies.
• A refill is an imperfect sign of unrelieved pain: it may also reflect physical dependence, withdrawal, or pain that non-opioid treatment could have handled.
• Refills were assumed to be for the same condition, which could not be confirmed.
• Factors linked to more refills, such as male sex or benzodiazepine use, may reflect conditions needing longer treatment rather than independent risks.

Sources

• Mallika L. Mundkur, Jessica M. Franklin, Younathan Abdia, Krista F. Huybrechts, Elisabetta Patorno, Joshua J. Gagne, Tamra E. Meyer, Judy Staffa and Brian T. Bateman, "Days' Supply of Initial Opioid Analgesic Prescriptions and Additional Fills for Acute Pain Conditions Treated in the Primary Care Setting — United States, 2014," Morbidity and Mortality Weekly Report, CDC: https://www.cdc.gov/mmwr/volumes/68/wr/mm6806a3.htm