Opioid tapering significantly increases risk for overdose, mental health crisis
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Patients who had their opioids tapered after receiving stable, long-term, higher-dose opioid therapy were at a significantly increased risk for overdose and mental health crisis than those who did not have reduced doses, data showed.
Researchers said the study raises questions about the “potential harms of tapering,” but the interpretation is limited by its observational design.
“There have been reports of patients becoming suicidal as their doses were reduced, and also overdose events,” Alicia Lauren Agnoli, MD, MPH, MHS, an assistant professor of family and community medicine at the University of California, Davis, Center for Healthcare Policy and Research, told Healio Primary Care. “We had the opportunity to examine the occurrence of these events in a large, national sample of patients.”
Agnoli and colleagues’ retrospective cohort study included adults who were prescribed stable, high-dose opioid therapy (mean of 50 or more morphine milligram equivalents daily) for a 12-month baseline period with at least 2 months of follow-up. The researchers defined opioid tapering as a 15% or more relative reduction in mean daily opioid dose during any of six overlapping 60-day windows within a 7-month follow-up period. A total of 113,618 hospital and ED patients with demographic and geographically diverse characteristics and 203,920 stable baseline periods were analyzed. The mean age of all participants was in the late 50s, slightly more than half were women and approximately 40% had commercial insurance.
Agnoli and colleagues wrote in JAMA that post-tapering periods were linked to an adjusted incidence rate of 9.3 overdose events for each 100 person-years compared with non-tapered periods, which were linked to 5.5 events for each 100 person-years (adjusted incidence rate difference by tapering status = 3.8 for each 100 person-years; 95% CI, 3-4.6; adjusted incidence rate ratio = 1.68; 95% CI, 1.53-1.85).
In addition, tapering was linked to an adjusted incidence rate of 7.6 mental health crisis events for each 100 person-years compared with 3.3 events for each 100 person-years among patients who did not have their doses reduced (adjusted incidence rate difference by tapering status = 4.3 for each 100 person-years; 95% CI, 3.2-5.3; adjusted incidence rate ratio = 2.28; 95% CI, 1.96-2.65).
Also, increasing the speed of maximum monthly dose reduction by 10% was linked to an adjusted incidence rate ratio of 1.09 for overdose (95% CI, 1.07-1.11) and 1.18 for mental health crisis (95% CI, 1.14-1.21).
The magnitude of the associations was “surprising,” Agnoli said in the interview.
“This could be just the tip of the iceberg of suffering that patients experience when tapering,” she said. “I don’t think health care systems are really doing very much to address this problem.”
She encouraged physicians who prescribe opioids to have a “very clear conversation” regarding the possible risks tied to opioid tapering.
“The decision to embark on tapering should depend on the patient’s goals and priorities, and when possible, the rate of dose reduction should be gradual,” Agnoli said. “Doctors should strive to see patients frequently and should be on the lookout for symptoms of withdrawal, worsening pain or depression [and] strive to implement recommendations outlined in the recent Health and Human Services Guideline for opioid dose reduction.”
In a related editorial, Marc LaRochelle, MD, MPH, an assistant professor of medicine at the Boston University School of Medicine, and colleagues wrote that “current policies and incentives discourage clinicians from providing” patient-centered care during opioid tapering, such as weekly patient check-ins conducted via in-office visits or through phone calls, prescribing less than 7 days’ worth of opioids at one time and prescribing naloxone and making sure the patient and all of his or her household members know how to use it.
“Guidelines and policies should expressly allow clinicians to continue long-term opioid therapy for established patients when benefits outweigh risks,” they wrote. “If the risk-benefit ratio is no longer favorable, including in cases of active [opioid use disorder], policies should permit ongoing prescribing as long as there is a documented plan for engaging the patient in a slow, monitored dose reduction or conversion to medications for managing [opioid use disorder].”
References:
Agnoli AM, et al. JAMA. 2021;doi:10.1001/jama.2021.11013.
Larochelle M, et al. JAMA. 2021;doi:10.1001/jama.2021.11118.
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Anita Gupta, DO, PharmD, MPP, GMP, FASA
The authors in the research address an emerging area of concern of mental health in the U.S. and the impact of medications and opioid use. Mental health is a growing area of concern as the drug crisis continues to rise during the COVID-19 pandemic.
Opioid dose tapering is, in particular, a critical area to explore as the risks from long-term opioids are well-documented, particularly at higher doses with co-existing risk factors for opioid toxicity. Multi-stakeholders, clinicians and patients must carefully weigh the risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy to obtain the best outcomes for patients.
Furthermore, there is a critical need to assess the benefits and risks associated with opioid tapering to guide best practice guidelines to ensure the optimal doses of medication and monitoring parameters, including mental health, while providing safe and responsible use of the opioid medications.
Agnoli and colleagues raise crucial questions on the impact mental health has on de-escalation that require further study and analysis. There is an unmet need of understanding how opioid tapering can potentially impact one’s long-term mental health in various complex medical conditions, diverse populations and those who may lack proper monitoring or access to health care.
Distinguished fellow, National Academics of Practice
Faculty member, departments of anesthesiology and critical care, Johns Hopkins School of Medicine
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Over the last several years, the U.S. has seen a dramatic increase in the use of prescription opioids, which has resulted in a significant increase in opioid addiction, dependence and overdose. This has led to the nationwide crackdown on their use, with states issuing stricter guidelines on their prescription by health care providers. The CDC has also urged physicians to de-escalate opioids when the risks associated with their use outweigh the benefits.
This observational study of a large patient population by Agnoli and colleagues provides a useful insight on the potential harmful effects associated with tapering opioids in patients with long-term use of high-dose opioids. Baseline anxiety or depression were included as co-variates; however, rates of psychiatry disorders such as schizophrenia, which can potentially play a role in the crisis and suicidal attempts, were not adjusted in the study.
An increase in the number of emergency room visits for withdrawal symptoms, suicidal attempts, and/or drug overdose was found. These events ultimately increase the utilization of health care resources and costs and put patient lives at risk.
This brings us to the next question as to which patients are suitable for safe de-escalation of opioids. Probably, the patients who are on smaller doses of opioids? It is important to recognize that the management of pain in opioid dependents is a complex issue. The involvement of pain management specialists is essential when changes in pain regimens are intended. Measures such as avoiding rapid de-escalation, providing psychosocial support, patient education on withdrawal signs and frequent follow-up visits can mitigate risks associated with opioid tapering. These can also assist in identifying adverse events at an early stage in high-risk individuals.
Before attempting opioid de-escalation, it is a good practice to review a patient’s history of psychiatric illnesses, suicidal attempts and drug overdose that can help the providers in stratifying patients at higher risk of adverse events. Controlled trials can provide further insights on patient selection and optimal regimens in dose reductions of opioids.
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