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

Discussion

In this cohort of Medicaid beneficiaries with an episode of chronic opioid therapy (COT), discontinuation of opioid prescriptions (abrupt or with dose reduction) increased the patient's risk of suicide or opioid-related adverse events in the following year. Patients with an abrupt discontinuation were more likely to overdose on heroin (vs. prescription opioids) or experience a fatal suicide than those in all other dose change groups. Patients on a stable or increasing dose were more likely to experience an overdose event. Patients who discontinued opioid prescriptions had higher odds of filling a buprenorphine prescription.

This study broadens our understanding of the potential risks of opioid discontinuation among individuals using high-dose COT. Similar to Mark and Parish,[29] we find that individuals with an abrupt discontinuation face increased risk for some harms, but we also find increased risk of overdose among those with a stable or increasing dose. Our findings extend these observations to a cohort of individuals with COT at a lower average dose (50 vs 120 MME daily) and highlight specific risks.

There has recently been a shift in deaths from prescription opioids to heroin and synthetic opioid overdose deaths.[34] Prescription opioid use or misuse is common among individuals who initiate heroin;[31] one study suggests that restrictive policies on prescription opioids, sometimes leading to opioid discontinuation, may precipitate heroin use.[25] Moreover, the combination of prescription opioid use before injection drug use is associated with increased overdose risk.[1] Consistent with these observations, we find that heroin-related overdose was more common among individuals who abruptly discontinued opioid prescriptions. We also found that fatal overdose was more common among individuals with a stable or increasing dose, although individuals in this group were also more likely to overdose on prescription opioids than heroin.

Growing evidence suggests the use of sublingual buprenorphine may confer analgesic effects in patients with chronic noncancer pain. In addition, opioid-dependent patients with chronic pain may benefit from reversal of opioid-induced hyperalgesia and improvement in opioid tolerance.[6,7,10] In this study, patients who discontinued opioid prescriptions or reduced their dose without ever discontinuing had higher odds of filling a buprenorphine prescription than those who had a stable or increasing dose, suggesting that some patients may be transitioned to buprenorphine. However, the degree to which people were switched to buprenorphine for opioid use disorder, chronic pain management, or both is unclear.

This study raises several important issues. Discontinuation after COT may increase risks of heroin overdose, suicide, or other adverse events, so discontinuation should be carefully considered in partnership with the patient. We found that opioid harms were most common among those with a dose reduction before discontinuation, so even when dose reduction is the best identified clinical course, clinical caution is merited.[28] Certain conditions may favor rapid tapering or discontinuation,[3] yet in general, the CDC guideline recommends slow dose reductions over a longer time period for patients with COT.[4] We found that stable or increasing dose of opioids carries a notable risk of fatal overdose as well as emphasize the importance of patient education and coprescriptions for naloxone.[9] Finally, after end of COT, patients had characteristics similar to patients with opioid use disorder (OUD)[15,23,39] as well as a high proportion of health services utilization for OUD (opioid misuse and opioid dependence) after opioid discontinuation or reduction.[43] Wei et al.[42] found that 50% of patients on chronic opioid therapy developed OUD within a year; therefore, tapering decisions should account for presence or risk of OUD in patients on COT to reduce any potential harms.

This study has several limitations. First, the observational design does not permit us to disentangle issues related to temporality and causation; we do not know why prescriptions were interrupted. Patients who were incarcerated or hospitalized may have erroneously appeared to discontinue use. The length of COT may be underestimated, and we cannot ascertain any differences in the length of COT across the 4 cohorts because we were limited by the start of our study period.[35]

The patient cohort is comprised entirely of Oregon Medicaid members so may not represent national patterns.[16] We also could not determine clinical indication for COT; thus, we could not evaluate the appropriateness of any opioid use nor could we determine the appropriateness of the identified dose reductions or discontinuations. As with all studies using claims data, we may underestimate risk if there was not a billed medical visit as a result of an overdose, suicide attempt, or other adverse event. To mitigate this limitation, we applied a continuous enrollment criterion and used PDMP data instead of pharmacy claims to ensure that we captured all opioid prescriptions including those paid with cash, and we used vital statistics data to identify fatal events that may not have been identified in claims.

In summary, discontinuation of prescription opioid dose after a period of high-dose long-term use is associated with an increased risk of suicide or other opioid-related harms, whereas a stable or increasing opioid dose is associated with an increased risk of opioid overdose. Our study suggests that patients on COT require careful risk assessment and supportive interventions when considering opioid discontinuation or continuation at a high dose.

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