Association between opioid therapy trajectories and potential opioid‐related adverse health events

Abstract

Purpose We identified associations between membership in seven group‐based trajectories based on supply of filled opioid prescriptions and potential opioid‐related adverse health events over a 720‐day window. Methods We identified two veteran cohorts with chronic non‐cancer pain who initiated treatment with long‐term opioid therapy between 2008 and 2015, excluding those with prior substance use disorder (n = 373 941) or non‐SUD, opioid‐related adverse outcome (n = 405 631) diagnoses. Outcomes of interest included opioid use disorder, non‐opioid drug use disorder, and alcohol use disorder for the first cohort; or accidents resulting in wounds or injuries, self‐inflicted injuries, opioid‐related accidents and overdoses, alcohol and non‐opioid drug‐related accidents and overdoses, and violence‐related injuries for the second cohort. Using a cross‐sectional design, Veterans were followed until the specific outcome of interest was diagnosed, they died, the study ended, or they were lost to follow up. Accelerated failure time models were estimated for each outcome. Results Membership in persistent moderate days covered and persistent modest days covered trajectories was associated with decreased risk of opioid use disorder (Moderate: θ = 0.59, 95%CI:0.54, 0.64; Modest: θ = 0.54, 95%CI:0.50, 0.59) and opioid overdose (Moderate: θ = 0.67,95%CI: 0.57, 0.79; Modest: θ = 0.72, 95%CI:0.61, 0.85) versus higher‐utilizing persistent users. Rapid discontinuation was associated with decreased risk of opioid use disorder (θ = 0.86, 95% CI:0.77, 0.95) and opioid overdose (θ = 0.54, 95%CI:0.41, 0.71), but increased risk of alcohol use disorder (θ = 1.07, 95%CI:1.00, 1.15) and other substance use disorders. Delayed discontinuation or delayed reduction was associated with increased risk for most opioid related adverse health events. Conclusion Persistent use trajectories with low levels of opioid utilization were associated with lower risks of potential opioid‐related adverse health events.

Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies

“…Twenty-four studies were conducted in the United States, 3 were conducted in Canada and 1 was conducted in the United Kingdom. Twenty-one studies 23 , 24 , 40 – 47 , 50 – 53 , 55 – 57 , 59 – 62 included only patients with chronic noncancer pain, and 7 27 , 28 , 39 , 48 , 49 , 54 , 58 included patients with either chronic noncancer or cancer-related pain. Twenty-two studies enrolled patients with previous or current substance use disorder (median proportion 9%, IQR 4%–13%), 23 , 24 , 27 , 28 , 39 – 43 , 46 , 48 – 51 , 53 – 55 , 57 , 58 , 60 – 62 and 3 studies excluded patients with comorbid substance use disorder.…”

“…Twenty-one studies 23 , 24 , 40 – 47 , 50 – 53 , 55 – 57 , 59 – 62 included only patients with chronic noncancer pain, and 7 27 , 28 , 39 , 48 , 49 , 54 , 58 included patients with either chronic noncancer or cancer-related pain. Twenty-two studies enrolled patients with previous or current substance use disorder (median proportion 9%, IQR 4%–13%), 23 , 24 , 27 , 28 , 39 – 43 , 46 , 48 – 51 , 53 – 55 , 57 , 58 , 60 – 62 and 3 studies excluded patients with comorbid substance use disorder. 45 , 52 , 56 Twenty-three studies included patients with comorbid mental illness (median proportion 31%, IQR 20%–41%), 23 , 24 , 27 , 28 , 40 – 42 , 45 – 49 , 51 – 58 , 60 – 62 and 5 studies exclusively recruited veterans.…”

“… 23 , 27 , 40 , 41 , 43 , 45 , 48 , 49 , 52 , 54 – 57 , 61 , 62 , 67 § In 22 studies. 23 , 24 , 27 , 28 , 39 – 43 , 46 , 48 – 51 , 53 – 55 , 57 , 58 , 60 – 62 Three studies explicitly excluded patients with comorbid substance use disorders. 45 , 52 , 56 ¶ In 23 studies.…”

Five-Year Trajectories of Prescription Opioid Use

“…A study of people 65 years or older with CNCP and new opioid use found that individuals with increasing or consistent opioid dose trajectories had a higher risk of opioid-related adverse events than those with decreasing opioid dose trajectories . Similarly, studies examining opioid use among US veterans identified higher risk of opioid-related adverse events, hospitalization, and all-cause mortality among high use and increasing use groups . Improved understanding of the characteristics of individuals with higher use trajectories could benefit clinicians who initiate opioid therapy, providing information to support monitoring and interventions to prevent future problems as well as assisting with improved targeting of resource-limited interventions where they are most likely to be of benefit.…”

Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain

“…32 Tapering opioids (sometimes called "deprescribing") has been identified as a key strategy in improving pain and reducing opioidrelated harms in patients using opioids for pain outside the context of active malignancy or palliation. 20,24,49 The 2010 Canadian Guideline for Safe and Effective use of Opioids for Chronic Noncancer Pain and the 2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain were updated in 2017 and 2022, respectively, both with greater communication around safe and effective deprescribing of opioids. 7,15,17,21 In Australia, a National Health and Medical Research Council (NHMRC) endorsed Evidence-Based Clinical Practice Guideline for Deprescribing Opioid Analgesics was published in September 2022 to guide clinicians on when and how to taper opioids.…”