Opioid dose, duration, and risk of use disorder in Medicaid patients with musculoskeletal pain

Importance The CDC recommends initiating opioids for pain treatment at the lowest effective dose and duration; however, how dose, duration, and drug type jointly influence opioid use disorder risk remains a critical gap not addressed by current guidelines. Objective We examine how interactions between dose, duration, and other medication factors (eg, drug type) influence opioid use disorder (OUD) risk. Design, Setting, Participants, Interventions Using Medicaid claims data (2016-2019) from 25 states, we analyzed opioid-naïve adults, newly diagnosed with musculoskeletal pain who initiated opioids within 3 months of diagnosis. A 6-month washout confirmed no prior opioid exposure or musculoskeletal diagnosis. Initial opioids were categorized by “dose-days supplied” (low [>0-20mg MME] to very high [>90mg MME] dose, and short [1-7days] to moderate [>7-30days] supply) and by opioid type; physical therapy (PT) sessions were also recorded. Using Poisson regression models, we estimated the OUD risk associated with dose-days categories, adjusting for baseline demographics, clinical characteristics, and medications. We separately examined opioid dose-days and PT, and assessed PT’s moderating effect on dose-days’ impact. Results Among 30 536 patients, half initiated opioids at 20-50 MME for 1-7days, and 20% received PT. OUD risk was 2-3 times higher for opioids initiated for >7-30days compared to 1-7days across doses, and 5.5 times higher for opioids initiated for >7-30days at >90 MME versus 1-7days at <20 MME. PT alone, neither affected OUD risk nor mitigated the increased risk from longer or higher dose opioids. Conclusions Our findings support the need for careful opioid prescribing and alternative pain management strategies, as the observed associations between initial prescription characteristics and OUD were not mitigated by adjunctive PT. Relevance This study demonstrated that initial opioid prescriptions of 7-30days, especially above 90 MME/day, increased OUD risk in opioid-naïve patients with musculoskeletal pain; physical therapy did not mitigate the risk. Different opioids posed varied risks, even at the same dose and duration. Careful prescribing and alternative pain management are essential.