Accurate Education – The Transition of Acute Opioid Use to Chronic Opioid Use

In this study group of 36,177 patients, the incidence of persistent opioid use for more than 90 days and up to 180 days after both minor and major surgical procedures was identified.  Minor surgeries included: varicose vein removal, laparoscopic gall bladder removal, laparoscopic appendectomy, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, and carpal tunnel surgery. Major surgical procedures included: ventral incisional hernia repair, colectomy, reflux surgery, bariatric surgery, and hysterectomy. The study identified 29,068 (80.3%) patients who had minor surgical procedures and 7109 (19.7%) who had major procedures.

The rates of new persistent opioid use were unexpectedly similar between both the minor and major surgical procedure groups, ranging from 5.9% to 6.5%, indicating that some patients likely continue opioids for reasons other than solely the intensity of surgical pain. By comparison, as would be expected, the incidence in the non-operative control group was less: only 0.4%. Of note, these results are also comparable with the 5% incidence of new long-term opioids use after the first opioid exposure based on data from the Oregon prescription drug monitoring program, which includes non-surgery related opioid prescriptions.

Another 2017 study of 1,294,247 patients published by the Center for Disease Control (CDC) evaluated the characteristics of initial opioid prescriptions and the likelihood of long-term opioid use in the United States from 2006–2015. This study found that 33,548 (2.6%) of patients continued opioid therapy for ≥1 year. This group was more likely to be older, female,  or to have a pain diagnosis before opioid initiation, to have been initiated on higher doses of opioids and were publicly or self-insured.

Among patients prescribed opioids, the probability of continued opioid use at 1 year was 6.0% and at 3 years was 2.9%. The probability of continued opioid use increased to 13.5% at one year for patients whose first time period of use was for ≥8 days and to 29.9% when the first time period of use was for ≥31 days. The risk for persistent opioid use at one year doubled when a second prescription was provided or when 700 morphine milligram equivalents (ME) or more as a cumulative dose was prescribed.

As addressed above and emphasized throughout this web site, pain perception is complex, with multiple variables that contribute to the severity and persistence of pain and, most importantly, the degree to which people suffer and/or are compromised by their pain. It requires diligence on the part of pain patients and their clinicians to take steps to reduce the incidence of preventable chronification of post-injury pain and opioid use.

Management Factors Related to Transition to Chronic Opioid Use

The most important variable in the transition of acute to chronic use of opioids is the effectiveness of pain management in the acute post-injury or post-surgical time period. The earlier acute post-injury or post-surgical pain is well controlled, the less likely the pain will become chronic (>3 months duration) and a shorter duration of opioid use would be expected. For more information in acute pain management and the transitioning of acute to chronic pain, see Acute Pain Transition to Chronic Pain.

It has been established that the transition from acute to chronic pain involves changes in the nervous system including the development of neuropathic pain (See: Neuropathic Pain) and a process of peripheral and central sensitization. Treatment directed at reducing central sensitizaton is an important component of managing acute pain in an effort to reduce the transition to chronic pain and therefore is expected to reduce the chronification of opioid use. (See: Central Sensitization).