Most patients with acute pain use opioids sparingly, study finds

Patients who are prescribed opioids for acute pain tend to use them sparingly and briefly, but a meaningful minority continue well past the point most guidelines consider appropriate, according to a study published in JAMA Network Open.

“These findings suggest many patients will be well-served by current guideline recommendations for an initial opioid prescription of short duration,” the authors wrote. “However, some patients did need to use opioids longer; treatment should be tailored to address individual patients’ needs.”

The prospective cohort study followed 1,708 opioid-naive patients recruited from five U.S. health systems — Cedars-Sinai Medical Center, Mayo Clinic, Monument Health, the University of Alabama at Birmingham and Yale-New Haven Health, along with dental practices in several Southeastern states — between September 2020 and March 2023. Patients were enrolled after being offered an opioid prescription in emergency departments, primary or urgent care clinics, dental practices, or after cesarean delivery or knee replacement, and were tracked for 180 days through digital surveys.

The research, known as the Acute Pain Pathways study, was mandated under the 2018 SUPPORT for Patients and Communities Act, which directed the FDA to help develop indication-specific opioid prescribing guidance. It was led by Molly Moore Jeffery of the Mayo Clinic and colleagues, including several FDA co-authors.

Among the findings was that median time to pain resolution across all pain types was 20 days, but that stretched to 74 days for surgical pain and 69 days for low back pain, compared with just eight days for kidney stones. Of the 1,189 patients who reported using an opioid, median time to discontinuation was seven days. Still, an estimated 10% of patients used opioids for at least 90 days, with the highest rates among those who reported frequent pain in the six months before their prescription.

Daily doses were generally low at a median of 10 morphine milligram equivalents, which is equivalent to about two 5-milligram hydrocodone tablets. Most patients combined opioids with nonopioid medications and nonpharmacologic approaches such as rest, ice or heat; 86.8% used acetaminophen or ibuprofen at some point in the first two weeks. Opioids provided modestly greater relief than other treatments, about 5.5 percentage points higher on a 100-point scale. Roughly a third of patients skipped opioids even on days when they rated their pain 8 or higher out of 10.

Nearly 67% of patients reported having leftover opioid tablets, a rate consistent with prior research on postsurgical and dental prescribing.

The study relied on self-reported treatment data rather than pharmacy or health-record confirmation, and enrollment was complicated by the COVID-19 pandemic and technical issues linking patient accounts to health records. The authors said the findings are descriptive and cannot establish cause and effect, but add real-world evidence to a literature that has lacked head-to-head data on opioid versus nonopioid treatment for acute pain.

“The findings suggest current guidelines for multimodal treatment and short-duration opioid prescriptions, if needed, will serve many patients but not all and that treatment should be tailored to address individual patients’ needs,” the authors concluded.