Patient outcomes after opioid dose reduction among patients with chronic opioid therapy

Abstract

The net effects of prescribing initiatives that encourage dose reductions are uncertain. We examined whether rapid dose reduction after high-dose chronic opioid therapy (COT) associates with suicide, overdose, or other opioid-related adverse events. This retrospective cohort study included Oregon Medicaid recipients with high-dose COT. Claims were linked with prescription data from the prescription drug monitoring program and death data from vital statistics, 2014 to 2017. Participants were placed into 4 mutually exclusive dose trajectory groups after the high-dose COT period, and Cox proportional hazard models were used to examine the effect of dose changes on patient outcomes in the following year. Of the 14,596 high-dose COT patients, 4191 (28.7%) abruptly discontinued opioid prescriptions, 1648 (11.3%) reduced opioid dose before discontinuing, 6480 (44.4%) had a dose reduction but never discontinued, and 2277 (15.6%) had a stable or increasing dose. Discontinuation, whether abrupt (adjusted hazard ratio [aHR] 3.63; 95% confidence interval [CI] 1.42-9.25) or with dose reduction (aHR 4.47,) significantly increased risk of suicide compared with those with stable or increasing dose. By contrast, discontinuation or dose reduction reduced the risk of overdose compared with those with a stable or increasing dose (aHR 0.36-0.62, 95% CI 0.20-0.94). Patients with an abrupt discontinuation were more likely to overdose on heroin (vs. prescription opioids) than patients in other groups (P , 0.0001). Our study suggests that patients on COT require careful risk assessment and supportive interventions when considering opioid discontinuation or continuation at a high dose.

Comparative Effectiveness of Opioid Tapering or Abrupt Discontinuation vs No Dosage Change for Opioid Overdose or Suicide for Patients Receiving Stable Long-term Opioid Therapy

“…17 A study of Oregon Medicaid recipients found adjusted hazard ratios for suicide of 3.6 for discontinuation and 4.5 for tapering. 18 A study using the same claims data set and similar definition of long-term opioid therapy as our study identified effect estimates between those in our study and those in prior studies, with an estimated adjusted incidence rate ratio of 1.3 for the association of dose tapering with overdose and 2.4 for the association of dose tapering with suicide attempts. 32 The present study offers 2 key methodological advances in the study of opioid tapering.…”

“…[12][13][14] Several observational studies have identified harms associated with opioid tapering and discontinuation, but they also have several limitations. [15][16][17][18] Many studies focused on opioid discontinuation, which is likely more destabilizing than gradual tapering. Furthermore, there is a high potential for confounding.…”

CDC Clinical Practice Guideline for Prescribing Opioids for Pain—United States, 2022

“…Patients receiving long-term, high-dosage opioid therapy for chronic pain are at increased risk for adverse events including overdose death ( 55 , 72 , 202 , 203 , 209 ). However, discontinuation of long-term, high-dosage opioid therapy has been associated with adverse events including mental health crisis, overdose events, and overdose death ( 71 – 73 , 210 , 211 ). In addition, opioid tapering has been found to be associated with subsequent termination of care ( 212 ).…”

Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment

“…We explored baseline characteristics previously shown to be associated with opioid tapering, discontinuation, dose variability, or overdose mortality. 6 , 17 , 29 , 30 , 31 , 32 Demographic characteristics included age on the index date, sex, and race and ethnicity as reported by patients during visit registration and recorded in the EHR. Race and ethnicity, Medicaid coverage, and the calendar year of the index date were assessed because they could impact management decisions and the outcomes.…”