First Opioid Prescription and Subsequent High-Risk Opioid Use: a National Study of Privately Insured and Medicare Advantage Adults

J Gen Intern Med. 2018 Dec;33(12):2156-2162. doi: 10.1007/s11606-018-4628-y. Epub 2018 Sep 11.


Background: National guidelines make recommendations regarding the initial opioid prescriptions, but most of the supporting evidence is from the initial episode of care, not the first prescription.

Objective: To examine associations between features of the first opioid prescription and high-risk opioid use in the 18 months following the first prescription.

Design: Retrospective cohort study using data from a large commercial insurance claims database for 2011-2014 to identify individuals with no recent use of opioids and follow them for 18 months after the first opioid prescription.

Participants: Privately insured patients aged 18-64 and Medicare Advantage patients aged 65 or older who filled a first opioid prescription between 07/01/2011 and 06/30/2013.

Main outcomes and measures: High-risk opioid use was measured by having (1) opioid prescriptions overlapping for 7 days or more, (2) opioid and benzodiazepine prescriptions overlapping for 7 days or more, (3) three or more prescribers of opioids, and (4) a daily dosage exceeding 120 morphine milligram equivalents, in each of the six quarters following the first prescription.

Key results: All three features of the first prescription were strongly associated with high-risk use. For example, among privately insured patients, receiving a long- (vs. short-) acting first opioid was associated with a 16.9-percentage-point increase (95% CI, 14.3-19.5), a daily MME of 50 or more (vs. less than 30) was associated with a 12.5-percentage-point increase (95% CI, 12.1-12.9), and a supply exceeding 7 days (vs. 3 or fewer days) was associated with a 4.8-percentage-point increase (95% CI, 4.5-5.2), in the probability of having a daily dosage of 120 MMEs or more in the long term, compared to a sample mean of 4.2%. Results for the Medicare Advantage patients were similar.

Conclusions: Long-acting formulation, high daily dosage, and longer duration of the first opioid prescription were each associated with increased high-risk use of opioids in the long term.

Keywords: health services research; pain; physician behavior; prescription drug abuse.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Analgesics, Opioid / administration & dosage*
  • Analgesics, Opioid / adverse effects*
  • Analgesics, Opioid / economics
  • Cohort Studies
  • Delayed-Action Preparations / administration & dosage
  • Delayed-Action Preparations / adverse effects
  • Delayed-Action Preparations / economics
  • Drug Compounding
  • Drug Prescriptions / economics
  • Female
  • Humans
  • Insurance, Health / economics
  • Insurance, Health / trends*
  • Male
  • Medicare Part C / economics
  • Middle Aged
  • Opioid-Related Disorders / diagnosis
  • Opioid-Related Disorders / economics
  • Opioid-Related Disorders / epidemiology*
  • Prescription Drug Misuse / economics
  • Prescription Drug Misuse / trends*
  • Retrospective Studies
  • United States / epidemiology
  • Young Adult


  • Analgesics, Opioid
  • Delayed-Action Preparations