It wasn’t more than a few years ago that “pain control” as a measure of patient satisfaction was still a broadly accepted metric of good medical care. As a result, false incentives were created that many would argue have artificially fueled the opioid epidemic in our country—as clinicians, we were encouraged to provide large supplies of opioid medications to ensure our patients were completely comfortable from their painful conditions under the misguided premise that, as long as pain was present, these medications would not be addictive. We now know that premise to be incorrect and we now find ourselves in the midst of our nation’s addiction epidemic that is showing few signs of slowing (1).
In an effort to stem the crisis, federal and state authorities, along with insurers and other payers, have enacted regulations that work at different points along the supply and demand continuum. One such strategy, met with some criticism (2), has been to restrict the duration of prescriptions for acute and chronic pain to three, five, and seven-day limits. But where do these time frames come from? As a clinician myself, I wanted to better understand these limits and explain their rationale here for our readers.
Factors Contributing to Long-Term Use
We now know that there is a solid body of evidence showing an increased risk of sustained opioid use after receiving an opioid prescription for an acute pain event in opioid naïve patients (3-9). Similarly, various studies have been able to identify risk factors for persistent use that “include preoperative pain, medical comorbidities, depression, a history of drug, alcohol, or tobacco use, lower socioeconomic status, and the use of benzodiazepines or antidepressants” (1, 3-8). Additionally, oversupply of opioids has been a significant problem. Studies have shown that “among those who abuse opioids, over 70 percent obtain opioids through diversion, and 40 to 50 percent receive the drug from family members or friends who have leftover pills” (9-11). It has also been shown that excessive opioid medications are both oversupplied and that most patients save leftover pills with inadequate rates of disposal (12-23). It seems reasonable, then, that some effort to restrict these supplies would be in order. But what is an appropriate initial supply?
The Three and Five-Day Limits
In 2017, the U.S. Centers Disease Control and Prevention issued a seminal Morbidity and Mortality Weekly Report, “Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use, United States 2006-2015 (24). Looking at both the single and three-year likelihood of continuing opioid use, the CDC was able to identify risk factors for sustained use of these drugs. A second prescription or refill, 700 morphine milligram equivalent cumulative dose, and an initial 10 or 30-day supply were identified as statistically significant risks. Most importantly, however, they found that the likelihood of long-term use increases dramatically after days three and five.
Source: U.S. Centers for Disease Control
Thus, the three and five-day rules were born—they are a specific limit designed to minimize the risk for continuing use.
The Seven-Day Limits
The graph above notes a significant increase in the risk of continuing use at days 3, 5, and 30, but day 7 is relatively flat. The seven-day rule, as it turns out, was not derived from the 2017 acute pain guidelines, but from an older CDC document, Morbidity and Mortality Weekly Report, CDC Guideline for Prescribing Opioids for Chronic Pain—United States 2016 (25). In those recommendations, the CDC noted that some experts felt that a [range of three to seven days] was reasonable for the management of acute pain, but that a supply greater than seven days was too long. As a result, the CDC issued the guideline that pain management strategies beyond day seven required aggressive use of non-opioid analgesics, stronger clinician oversight, and use of strategies to taper continuing use. Based on those recommendations, the seven-day prescribing limit has now been integrated into the newer prescribing rules seen in federal, state, and payer policies.
The CDC guidelines above represent the best scientifically driven efforts to inform responsible opioid prescribing. What they do not, do, however, is address the difficulty that many patients have in accessing their physicians and pain management providers who can help guide them through a coherent pain management strategy. As the guidelines clearly illustrate, minimizing the risk for longer term opioid use requires a multifactorial approach that includes nonopioid analgesic measures as well as attention to the underlying socioeconomic issues that drive opioid utilization. Unfortunately, that is part of a much bigger discussion we are continuing to have in our country around access to affordable health care and one we will continue to struggle with for the foreseeable future.
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