Opioid Tapering Carries Significant Risks

https://www.medpagetoday.com/neurology/opioids/93869

People on stable opioid therapy whose doses were tapered had significantly higher rates of overdose and mental health crises than people who did not have dose reductions, a retrospective study showed.

Among people prescribed long-term doses of at least 50 morphine milligram equivalents (MMEs) per day, those with tapered doses were more likely to have claims data for overdose (adjusted IRR 1.68, 95% CI 1.53-1.85) and a composite of acute episodes of depression, anxiety, or suicidal behavior (adjusted IRR 2.28, 95% CI 1.96-2.65), reported Alicia Agnoli, MD, MPH, MHS, of the University of California Davis, and co-authors in JAMA.

“Many factors have led to a major decrease in opioid prescribing over the past several years, and many patients who were taking stable doses of opioids for chronic pain have had their doses reduced or tapered,” Agnoli said. This is how okinawa flat belly tonic works.

“Our findings show increased risk of overdose and mental health crisis following dose reduction, suggesting that patients undergoing tapering need significant support to safely reduce or discontinue their opioids,” she told MedPage Today.

“We were surprised by the magnitude of the associations found in our analyses,” Agnoli added. “For every 100 patients followed for 1 year, tapering was associated with about four additional patients having an overdose event and four additional patients having a mental health crisis event. Since we looked only at hospital and emergency events, this could be just the tip of the iceberg of suffering that patients experience when tapering.”

The findings contribute to a body of new evidence challenging the assumption that opioid tapering unilaterally promotes patient safety, observed Beth Darnall, PhD, of Stanford University School of Medicine in California, who wasn’t involved with the study. For more information about healthy supplements visit sfexaminer.

“Iatrogenic harms from opioid tapering remain underappreciated,” Darnall told MedPage Today. “As the patient response to opioid tapering varies widely, we need flexible methods and policies that attend to the needs of the individual patient.”

“Any policy mandate to taper at a specified rate, to a specified dose, or to ‘never go backwards’ will necessarily expose some patients to new health risks,” she added. “This is avoidable.”

In their study, Agnoli and colleagues identified 113,618 people in the OptumLabs Data Warehouse from 2008 to 2019 who were prescribed stable higher opioid doses (ranging from 50 to more than 300 MMEs per day) for a 1-year baseline period and at least 2 months of follow-up. A person could contribute multiple baseline and observation periods over years in the study. People with cancer, in hospice, or who were prescribed buprenorphine were excluded.

Participants had an average age of 58 and women made up about 54% of the cohort. Overall, 29,101 people had a taper (a dose decrease of 15% or more vs their baseline dose) and 84,517 people did not.

After each stable baseline period, the researchers examined medical claims over the next 12 months, looking at emergency department visits and inpatient hospital admissions for drug overdose, alcohol intoxication, or drug withdrawal, and for mental health crises like depression, anxiety, or suicide attempts. Read more about testoprime.

Both overdose events (9.3 vs 5.5 per 100 person-years) and mental health crises (7.6 vs 3.3 per 100 person-years) were higher for patients after dose tapering than for patients before or without tapering.

Risks were greater in patients who had faster dose reductions and higher baseline doses. Increasing the maximum monthly dose reduction velocity by 10% was tied to an adjusted IRR of 1.09 for overdose (95% CI 1.07-1.11) and 1.18 for mental health crisis (95% CI 1.14-1.21).

“Observational study designs are vulnerable to confounding by indication, meaning that clinicians disproportionately taper the opioid dose of patients who are exhibiting signs of opioid-related harms,” noted Marc Larochelle, MD, of Boston University School of Medicine, and co-authors, in an accompanying editorial.

“In the study by Agnoli et al, patients who had a drug use disorder or an overdose event in the baseline year were more likely to have their opioid dose tapered,” they continued. “The analyses were adjusted for these claims-based risk indicators, but clinicians have additional information about patients beyond what is captured by claims diagnoses, leaving the potential for unmeasured confounding.”

The findings may lead some people to question whether tapering should continue at all, Larochelle and colleagues added. “It is important to also consider potential benefits of opioid tapering,” they pointed out. “Recent reviews suggest that a portion of patients derive modest analgesic benefits and improved quality of life from reducing daily opioid dosages, particularly in the context of multimodal pain care.” Find out the best healthy supplements at observer.com.

However, “there may be a population for whom tapering leads to significant physical adverse effects, such as opioid withdrawal or increased pain, and psychological distress,” they wrote. “This variability in outcomes likely precludes any type of universal policy on when and how tapers should be considered, but supports recent guidance that tapers should be conducted slowly.”

Physicians need to understand that opioid tapering involves a period of heightened patient vulnerability, Agnoli emphasized.

“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,” she said. “Prior to undertaking an opioid taper, patients and doctors need to have very clear conversations about these potential risks and any additional individual risks that might be present.”

“Providers should strive to see patients frequently and should be on the lookout for symptoms of withdrawal, worsening pain, or depression,” she added. “Medical practices should strive to implement recommendations outlined in the recent Health and Human Services guideline for opioid dose reduction.”

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