Patient Outcomes After Opioid Dose Reduction Among Patients With Chronic Opioid Therapy

Sara E. Hallvik; Sanae El Ibrahimi; Kirbee Johnston; Jonah Geddes; Gillian Leichtling; P. Todd Korthuis; Daniel M. Hartung

Disclosures

Pain. 2022;163(1):83-90. 

In This Article

Results

The linked data set contained 354,841 patients with Medicaid eligibility and an opioid prescription or opioid-related diagnoses between 2014 and 2017. Of these, 20,575 (5.8%) patients had at least one episode of high-dose COT that ended in 2014 or 2015 (Figure 1).

Of the 14,596 high-dose COT patients that met continuous enrollment criteria, 4191 (28.7%) abruptly discontinued opioid prescriptions in the year after high-dose COT, 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 in the year after the COT episode (Figure 1).

Patients with an abrupt discontinuation had the highest daily average MME during the COT episode (mean 146.08, SD 735.53), whereas patients with a stable or increasing dose had the lowest average MME (mean 103.46, SD 76.49) (Table 1). Patients who discontinued opioid prescriptions (abruptly or with a preceding dose reduction) were younger and less likely to be female than patients who did not discontinue opioid prescriptions (with or without a dose reduction). Patients with a dose reduction and discontinuation were more likely to have a multiple prescriber or pharmacy episode during COT or diagnoses of chronic pain, depression, alcohol abuse, or any drug abuse in the 3 months before the end of the COT than patients in other groups (Table 1).

Overall, 625 (4.3%) patients had an opioid-related event (Table 2). Patients who discontinued opioid prescriptions (with or without a dose reduction) were more likely to have a suicide event (1.0% and 1.4% vs 0.3% and 0.2%) or experience some other opioid-related harm (3.8% and 4.6% vs 2.7% and 1.9%) than those who did not discontinue (P < 0.0001). Patients with a stable or increasing dose were most likely to experience an opioid overdose (1.7%, P = 0.0002) (Table 2).

Among patients with an opioid overdose, those who abruptly discontinued opioid prescriptions were more likely than patients in all other groups to overdose on heroin vs prescription opioids (n = 8, 14.8%, P = 0.0622), whereas patients with a stable or increasing dose were more likely to experience a fatal overdose (n = 27, 67.5%, P < 0.0001). Among patients with a suicide event, those with an abrupt discontinuation were more likely to experience a fatal event (n = 23, 57.5%, P < 0.0001) than patients in other dose change groups (Table 2).

Patients with an abrupt discontinuation (n = 192, 4.6%) or dose reduction before discontinuation (n = 83, 5.0%) were more likely to have filled at least one buprenorphine prescription during the follow-up period than patients in other dose change groups (P < 0.0001) (Table 2).

Discontinuation significantly increased risk of suicide compared with those with stable or increasing dose (abrupt, adjusted hazard ratio [aHR] 3.63; 95% confidence interval [CI] 1.42–9.25 or with dose reduction, aHR 4.47, 95% CI 1.68–11.88), whereas 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) (Table 3).

Those with an abrupt discontinuation (aOR 15.07, 95% CI 7.28–38.38), dose reduction and discontinuation (aOR 14.83, 95% CI 7.00–38.33), or dose reduction without discontinuation (aOR 2.47, 95% CI 1.14–6.46) all had higher odds of filling a buprenorphine prescription relative to those with a stable or increasing dose (Table 3). Full models with adjusted covariates and survival curves can be found in Table 1, Appendix B (available at http://links.lww.com/PAIN/B360).

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