Opioid tapering associated with more hospital visits, fewer primary care visits

Opioid tapering was associated with “unintended negative consequences,” including fewer primary care visits, more hospitalization and ED visits and reduced chronic condition medicine adherence, researchers reported in JAMA Network Open.

Elizabeth M. Magnan, MD, PhD, an associate professor in residence at the University of California, Davis, Health Medical Center, and colleagues wrote that the tapering of long-term opioid therapy has grown since the CDC issued prescription opioid guidance in 2016, which has since been updated, to reduce overdose risks. However, the researchers noted that tapering “may disrupt clinical stability,” increasing the risk for overdose, suicide and worsened pain control and diminishing patient trust.

“A better understanding is needed of the potential negative outcomes associated with use of health care services and tapering, particularly among patients with comorbid chronic conditions requiring regular ambulatory care,” they wrote.

The researchers conducted a retrospective cohort analysis of administrative claims data spanning from Jan. 1, 2008, to Dec. 31, 2019. Patients were eligible if they were prescribed long-term opioid therapy at a dose of 50 morphine mg equivalents or more a day through a 12-month baseline period.

The overall study cohort consisted of 113,604 patients, who had a mean age of 58 years. The researchers also examined subcohorts of patients with diabetes (n = 23,335) and patients with hypertension (n = 41,207) who took antidiabetic and antihypertension medication for more than 60 days, respectively.

Magnan and colleagues found that tapering was significantly associated with more ED visits (adjusted incidence rate ratio [IRR] = 1.19; 95% CI, 1.16-1.21) and hospitalizations (aIRR = 1.16; 95% CI, 1.12-1.2) in the overall cohort, along with both subcohorts.

In addition, it was associated with fewer primary care visits in the overall cohort (aIRR = 0.95; 95% CI, 0.94-0.96) and hypertension subcohort (aIRR = 0.98; 95% CI, 0.97-0.99).

“Collectively, these findings suggest that tapering was associated with a decrease in PC visits in the same period as an increase in higher cost, higher acuity care,” the researchers wrote. “Reduced PC visits after tapering may have arisen due to the lack of perceived need for PC or fracture in the PCP-patient relationship.”

They also highlighted that the subcohort of patients with diabetes was the only one to not experience fewer primary care visits.

“This could be due to a stronger patient-PCP relationship developed over more visits for diabetes care that is robust to reductions in trust or that the treatment needs for diabetes protect against reductions in PC visit frequency,” they wrote.

Tapering was also associated with decreased medication adherence in patients with hypertension (aIRR = 0.6; 95% CI, 0.59-0.62) and patients with diabetes (aIRR = 0.69; 95% CI, 0.67-0.71), as well as with small increases in diastolic BP and HbA1c levels.

Magnan and colleagues wrote that medication adherence associations potentially emerged from several factors, including increased patient focus on managing psychological distress, disruption in primary care or fractured relationships between physicians and patients.

They noted that a reduced need for antidiabetic and antihypertension medications was unlikely as resolutions of hypertension or diabetes were not expected following tapering.

“Although cautious interpretation is warranted, these outcomes may represent unintended negative consequences of opioid tapering in patients who were prescribed previously stable doses,” the researchers concluded.