FDA on opioids

[Aether2000]

21% episodic use and 6% long term use one year after initiation of opioids
Mayo Clin Proc. 2015 Jul;90(7):850-6. doi: 10.1016/j.mayocp.2015.04.012.
Incidence and Risk Factors for Progression From Short-term to Episodic or Long-term Opioid Prescribing: A Population-Based Study.
Hooten WM1, St Sauver JL2, McGree ME3, Jacobson DJ3, Warner DO4.
Author information

Abstract
OBJECTIVES:
To determine what proportion of a geographically defined population who receive new opioid prescriptions progresses to episodic or long-term patterns of opioid prescribing and to explore the clinical characteristics associated with patterns of opioid prescribing.

PATIENTS AND METHODS:
Population-based drug prescription records for the population of Olmsted County between January 1 and December 31, 2009, were obtained using the Rochester Epidemiology Project medical records linkage system (N=142,377). All medical records were reviewed for a random sample of 293 patients who had a new ("incident") prescription for an opioid analgesic in 2009. Patients were followed through their medical records for 1 year after their initial prescription date, with patterns of opioid prescribing categorized as short-term, episodic, or long-term.

RESULTS:
Overall, 293 patients received 515 new opioid prescriptions in 2009. Of these, 61 (21%) progressed to an episodic prescribing pattern and 19 (6%) progressed to a long-term prescribing pattern. In multivariable logistic regression analyses, substance abuse was significantly associated (P<.001) with a long-term opioid prescribing pattern as compared with an short-term opioid prescribing pattern. Past or current nicotine use (P=.03) and substance abuse (P=.04) were significantly associated with an episodic or long-term prescribing pattern as compared with a short-term prescribing pattern.

CONCLUSION:
Knowledge of the clinical characteristics associated with the progression of a short-term to an episodic or long-term opioid prescribing pattern could aid in the identification of at-risk patients and provide the basis for developing targeted clinical interventions.

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[Aether2000]

3.1% Use of Opioids 90 Days after Surgery- long enough to become chemically depndent
BMJ. 2014 Feb 11;348:g1251. doi: 10.1136/bmj.g1251.
Rates and risk factors for prolonged opioid use after major surgery: population based cohort study.
Clarke H1, Soneji N, Ko DT, Yun L, Wijeysundera DN.
Author information

Abstract
OBJECTIVE:
To describe rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery.

DESIGN:
Population based retrospective cohort study.

SETTING:
Acute care hospitals in Ontario, Canada, between 1 April 2003 and 31 March 2010.

PARTICIPANTS:
39,140 opioid naïve patients aged 66 years or older who had major elective surgery, including cardiac, intrathoracic, intra-abdominal, and pelvic procedures.

MAIN OUTCOME MEASURE:
Prolonged opioid use after discharge, as defined by ongoing outpatient prescriptions for opioids for more than 90 days after surgery.

RESULTS:
Of the 39,140 patients in the entire cohort, 49.2% (n=19,256) were discharged from hospital with an opioid prescription, and 3.1% (n=1229) continued to receive opioids for more than 90 days after surgery. Following risk adjustment with multivariable logistic regression modelling, patient related factors associated with significantly higher risks of prolonged opioid use included younger age, lower household income, specific comorbidities (diabetes, heart failure, pulmonary disease), and use of specific drugs preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin converting enzyme inhibitors). The type of surgical procedure was also highly associated with prolonged opioid use. Compared with open radical prostatectomies, both open and minimally invasive thoracic procedures were associated with significantly higher risks (odds ratio 2.58, 95% confidence interval 2.03 to 3.28 and 1.95 1.36 to 2.78, respectively). Conversely, open and minimally invasive major gynaecological procedures were associated with significantly lower risks (0.73, 0.55 to 0.98 and 0.45, 0.33 to 0.62, respectively).

CONCLUSIONS:
Approximately 3% of previously opioid naïve patients continued to use opioids for more than 90 days after major elective surgery. Specific patient and surgical characteristics were associated with the development of prolonged postoperative use of opioids. Our findings can help better inform understanding about the long term risks of opioid treatment for acute postoperative pain and define patient subgroups that warrant interventions to prevent progression to prolonged postoperative opioid use.
BMJ. 2014 Feb 11;348:g1251. doi: 10.1136/bmj.g1251.
Rates and risk factors for prolonged opioid use after major surgery: population based cohort study.
Clarke H1, Soneji N, Ko DT, Yun L, Wijeysundera DN.
Author information

Abstract
OBJECTIVE:
To describe rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery.

DESIGN:
Population based retrospective cohort study.

SETTING:
Acute care hospitals in Ontario, Canada, between 1 April 2003 and 31 March 2010.

PARTICIPANTS:
39,140 opioid naïve patients aged 66 years or older who had major elective surgery, including cardiac, intrathoracic, intra-abdominal, and pelvic procedures.

MAIN OUTCOME MEASURE:
Prolonged opioid use after discharge, as defined by ongoing outpatient prescriptions for opioids for more than 90 days after surgery.

RESULTS:
Of the 39,140 patients in the entire cohort, 49.2% (n=19,256) were discharged from hospital with an opioid prescription, and 3.1% (n=1229) continued to receive opioids for more than 90 days after surgery. Following risk adjustment with multivariable logistic regression modelling, patient related factors associated with significantly higher risks of prolonged opioid use included younger age, lower household income, specific comorbidities (diabetes, heart failure, pulmonary disease), and use of specific drugs preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin converting enzyme inhibitors). The type of surgical procedure was also highly associated with prolonged opioid use. Compared with open radical prostatectomies, both open and minimally invasive thoracic procedures were associated with significantly higher risks (odds ratio 2.58, 95% confidence interval 2.03 to 3.28 and 1.95 1.36 to 2.78, respectively). Conversely, open and minimally invasive major gynaecological procedures were associated with significantly lower risks (0.73, 0.55 to 0.98 and 0.45, 0.33 to 0.62, respectively).

CONCLUSIONS:
Approximately 3% of previously opioid naïve patients continued to use opioids for more than 90 days after major elective surgery. Specific patient and surgical characteristics were associated with the development of prolonged postoperative use of opioids. Our findings can help better inform understanding about the long term risks of opioid treatment for acute postoperative pain and define patient subgroups that warrant interventions to prevent progression to prolonged postoperative opioid use.

 

[Aether2000]

7.7% incidence of continuing opioids 1 year after surgery in opioid naive patients: Those receiving an opioid script within the first 7 days after surgery were 44% more likely to continue using opioids after a year.
Arch Intern Med. 2012 Mar 12;172(5):425-30. doi: 10.1001/archinternmed.2011.1827.
Long-term analgesic use after low-risk surgery: a retrospective cohort study.
Alam A1, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM.
Author information

Abstract
BACKGROUND:
This study evaluated the risk of long-term analgesic use after low-risk surgery in older adults not previously prescribed analgesics.

METHODS:
We conducted a retrospective cohort study using linked, population-based administrative data in Ontario, Canada, from April 1, 1997, through December 31, 2008. We identified Ontario residents 66 years and older who were dispensed an opioid within 7 days of a short-stay surgery (cataract surgery, laparoscopic cholecystectomy, transurethral resection of the prostate, or varicose vein stripping) and assessed the risk of long-term opioid use, defined as a prescription for an opioid within 60 days of the 1-year anniversary of the surgery. In a secondary analysis, we examined the risk of long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). We used multivariate logistic regression to examine the association between postsurgical use of analgesics and long-term use.

RESULTS:
Among 391,139 opioid-naive patients undergoing short-stay surgery, opioids were newly prescribed to 27,636 patients (7.1%) within 7 days of being discharged from the hospital, and opioids were prescribed to 30,145 patients (7.7%) at 1 year from surgery. An increase in the use of oxycodone was found during this time (from 5.4% within 7 days to 15.9% at 1 year). In our primary analysis, patients receiving an opioid prescription within 7 days of surgery were 44% more likely to become long-term opioid users within 1 year compared with those who received no such prescription (adjusted odds ratio, 1.44; 95% CI, 1.39-1.50). In a secondary analysis, among 383,780 NSAID-naive patients undergoing short-stay surgery, NSAIDs were prescribed to 1169 patients (0.3%) within 7 days of discharge and to 30,080 patients (7.8%) at 1 year from surgery. Patients who began taking NSAIDs within 7 days of surgery were almost 4 times more likely to become long-term NSAID users compared with patients with no such prescription (adjusted odds ratio, 3.74; 95% CI, 3.27-4.28).

CONCLUSION:
Prescription of analgesics immediately after ambulatory surgery occurs frequently in older adults and is associated with long-term use.