Tools for Practice

#240 What is the Incidence of Iatrogenic Opioid Use Disorder? 

What is the risk of developing opioid use disorder (OUD) when taking prescription opioids?

The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent). 

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  • Systematic review1 (12 studies, 310,408 patients): Pain patients prescribed opioid therapy (≥7 days and 97% had ≥3 months). 
    • Incidence of opioid dependence or “abuse” was 3.1% in higher quality studies. 
      • 4.7%, if all studies included. 
    • Diagnostic criteria matter: incidence varies (from 1-11%) with different diagnostic criteria. 
  • Systematic review2 (24 studies, 2507 patients): chronic pain patients prescribed opioid therapy, average exposure 26 months (range: 2-240). 
    • Incidence of opioid addiction was 3.3% 
      • 0.2% in patients without a history of “substance abuse/addiction” versus 5% with positive history.
    • Limitations: Varying addiction definitions; quality of trials included: retrospective (71%), prospective and/or randomized (29%); unclear pooling technique. 
  • Two systematic reviews:3,4 incidence 0.3%-0.5% but generally lower risk patients.3,4 
  • Incidence: new cases of OUD after opioid prescription and may better estimate latrogenic OUD than prevalence. Prevalence: all OUD patients, including those who obtained prescribed opioids after developing OUD.2 
  • Prevalence of OUD ranges from 0.05%-23%.3, 5-10 
    • Wide variation attributable to differing study quality, variable diagnostic criteria/terminology, inconsistent reporting, and populations studied. 
  • Majority of included studies (using terms like “addiction” or “substance abuse”) published before DSM-V criteria.  
  • Exposure to prescription opioids in adolescents and young adults was associated with future non-medical prescription opioid use11 and OUD.12 
  • From one insurance database cohort study (568,640 patients), after 12 months:13 
    • Duration: For doses 36-120mg/day morphine equivalent, OUD incidence with acute use (1-90 days) was 0.12% versus 1.3% with chronic use (prescriptions >90 days).
    • Dose: For prescriptions >90 days, OUD incidence with 1-36mg/day morphine equivalents was 0.7% versus 6.1% with >120mg/day morphine equivalent. 

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  • G. Michael Allan MD CCFP
  • Samantha Moe PharmD

1. Higgins C, Smith BH, Matthews K. Br J Anesthesia 2018; 120:1335-44.

2. Fishbain DA, Cole B, Lewis J et al. Pain Medicine 2008; 9:444-59.

3. Noble M, Treadwell JR, Tregear SJ, et al. Cochrane Database Syst Rev 2010, Issue 1, Art No.: CD006605.

4. Minozzi S, Amato L, Davoli M. Addiction. 2013 Apr;108(4):688-98.

5. Chou R, Turner JA, Devine EB, et al. Ann Intern Med 2015; 162:276-86.

6. Martell BA, O’Connor PG, Kerns RD, et al. Ann Intern Med 2007; 146:116-27.

7. Noble M, Tregear SJ, Treadwell JR et al. J Pain Symptom Manage 2008; 35(2): 214-28.

8. Roland CL, Lake J, Oderda GM. J Pain Palliat Care Pharmacother 2016; 30(4): 258-68.

9. Voon P, Karamouzian M, Kerr T. Subst Abuse Treat Prev Policy 2017; 12(1):36.

10. Vowles KE, McEntee ML, Julnes PS, et al. Pain 2005; 156(4):569-76.

11. McCabe SE, Veliz P, Schulenberg JE. Pain 2016; 157(10):2173-8.

12. Schroeder AR, Dehghan M, Newman TB et al. JAMA Intern Med 2019; 179(20): 145-152.

13. Edlund MJ, Martin BC, Russo JE et al. Clin J Pain 2014; 30(7):557-564.

Authors do not have any conflicts of interest to declare.