Background Opioid prescribing for non-cancer pain has increased dramatically. We examined whether the prevalence of unhealthy lifestyles, psychological distress, healthcare utilization, and co-prescribing of sedative-hypnotics increased with increasing duration of prescription opioid use. Methods We analyzed electronic data for 6 months before and after an index visit for back pain in a large managed care plan. Use of opioids was characterized as “none”, “acute” (≤ 90 days), “episodic”, or “long-term.” Associations with lifestyle factors, psychological distress, and utilization were adjusted for demographics and comorbidity. Results There were 26,014 eligible patients. Among these, 61% received a course of opioid therapy, and 19% were long-term users. Psychological distress, unhealthy lifestyles, and utilization were associated in stepwise fashion with duration of opioid prescribing, not just with chronic use. Among long-term opioid users, 59% received only short-acting drugs; 39% received both long and short acting drugs; 44% received a sedative-hypnotic. Of those with any opioid use, 36% had an emergency visit. Conclusions Opioid prescribing was common among patients with back pain. The prevalence of psychological distress, unhealthy lifestyles, and healthcare utilization increased incrementally with duration of opioid use. Despite safety concerns, co-prescribing of sedative-hypnotics was common. These data may help in predicting long-term opioid use and improving the safety of opioid prescribing.

We found that alerts in an outpatient electronic medical record aimed at decreasing prescribing of medication use in elderly persons may be an effective method of reducing prescribing of contraindicated medications. The effect of the alerts on patient outcomes is less certain and deserves further investigation.

Factors associated with high-dose opioid therapy for non-cancer pain are poorly understood. We document the prevalence of high-dose opioid use, as well as associated demographic, clinical, and health service utilization correlates among low back pain patients. Patients prescribed higher-dose opioids (≥100 mg/day morphine equivalent at last dispensing; n=453) and receiving opioids for 90+ consecutive days were compared to two groups: lower-dose (1–99 mg/day; n=4,815) or no opioid use (n=10,184). Higher-dose opioid use occurred in 2.9% of patients who received any opioids and in 8.6% of patients who received opioids long-term. The median dose in the higher-dose group was 180.0 mg/day. Compared to the no opioid group, higher-dose users reported poorer health. Compared to either comparison group, patients in the higher-dose group had higher rates of mental health and substance use disorders, concurrent sedative-hypnotic use (60.5%; n=274), and health service utilization. After adjusting for select covariates, male gender (Odds ratio (OR) 1.68, 95%CI 1.37,2.06), higher comorbidity, Medicare coverage (OR 1.65, 95% CI 1.22,2.23), any mental health or substance use diagnosis (OR 1.58, 95% CI 1.28,1.95), co-prescriptions of sedative-hypnotics (OR 1.75, 95% CI 1.42,2.16), and more Emergency Department and specialty pain clinic visits were associated with higher likelihood of high-dose prescriptions.

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All 3 interventions were effective in increasing laboratory monitoring when initiating new medications in primary care. Further work is necessary to determine if these interventions improve patient outcomes.