Opioid Scripts for Acute Pain in Primary Care: Factors Affecting Refill within 30 Days
When acute pain seen in primary care is treated with an initial opioid Rx, what factors are related to request for refill within 30 days?
Predicting & Preventing Prescription Opioid Misuse: What Factors May Help Predict Opioid Refill in 30 Days
The new study examined what factors were associated with a request for a prescription refill during the 30 days following an initial prescription for acute pain in primary care settings. Using data from a 2014 commercial insurance claims database, records were obtained for 176 607 patients with aprimary care visit associated with a complaint of acute pain; 13 400 filled an opioid prescription within 7 days of initial visit.
The 10 acute pain conditions for which opioid prescriptions were written: back pain with radiculopathy, back pain without radiculopathy, neck pain, joint pain, tendon/bursal pain, muscle strains/sprains, musculoskeletal injury (eg, ligamentous tears), urinary calculus, headache, dental pain.
Median initial prescriptions across conditions were written for from 4 to 7 days, 20 to 30 tablets, 100 to 150 morphine milligram equivalents (MME).
Overall, 17.8% of patients who filled an opioid prescription obtained at least 1 refill within 30 days after the initial prescription. Increased likelihood of a refill was associated with being male and history of recent use of benzodiazepines (26.%); sedative hypnotics (20%); gabapentin (28.3%).
Greater length of initial prescription appeared to reduce likelihood of need for refill in cases of back pain with radiculopathy, nephrolithiasis, and dental pain. The probability of refill remained relatively constant, regardless of initial amount, for other conditions-- joint pain, non-radicular back pain.
Overall, probability of obtaining a refill for 9 of the 10 conditions was <25%. Probability of obtaining a refill after the initial 7-day supply ranged from 11% for headache to 41% for musculoskeletl injury, suggesting variation among patients in time to recovery as well as in individual clinician prescribing practice and access to nonopioid treatment modalities. Results suggest that the majority of patients are receiving sufficient opioids for management of acute pain- and also that some patients may be receiving more pills or for a longer period than needed.
The authors did not speculate on the finding that recent use of benzodiazepines, sedative hypnotics, or gabapentin appears to increase the likelihood of a request for an opioid refill-but there are possible explanations.
The study authors note several limitations: First, Rx filling behaviors since 2014 may potentially be influenced by factors external to patients eg, policies set by states, health systems, stakeholders. Second, need for refill may reflect factors other than need for additional opioid therapy ie, physical dependence, withdrawal or additional pain control that might respond to a nonopioid. Third there was no verification that Rx refill was for the same pain condition. Fourth, factors associated with higher refill rates (ie, male sex, use of benzodiazepines) should be considered with caution as they could be linked to conditions requiring longer duration of treatment vs being risk factors for additional refills.
Take Home Points
- ~7-day opioid Rx for acute pain may be sufficience for some but not all patients; treatment strategies must account for patient- and condition-specific factors that could extend/reduce duration of therapy.
- Further research required to identify factors and traits that help predict which patients will go on to extended use, possible misuse.
- Physicians will be better able to assess optimal intensity/duration of opioid therapy for acute pain and limit excess that could potentially be misused by patient, others.
Management of acute pain is one of the primary indications for opioid analgesics. Prescriptions intended for short-term use, however, are under increasing scrutiny for potential contribution to the epidemic misuse of the drugs; in many regions limits are now imposed on number of pills and number of refills. Mundkur et al sought to identify factors that would help clinicians assess which patients might have more difficulty discontinuing opioids than others after expected resolution of acute pain. The study, highlighted in the slides below, was published online, Feb 15, 2019 by Morbidity and Mortality Weekly Report. Dr King is a pain physician in private practice in Philadelphia, Penn.
