Research: Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering
Author: Joshua Fenton, MD, MPH, et al.
Abstract: Is opioid dose tapering associated with reduced longer-term risks of overdose, withdrawal, or mental health crisis in patients who have been prescribed long-term opioids?
In this study of 19,377 patients, in both pre- and post-taper periods, the adjusted incidence rate ratios were 1.57 for overdose-withdrawal and 1.52 for a mental health crisis. Both were significant—suggesting that opioid dose tapering is associated with increased risks of overdose-withdrawal and mental health crisis that persist for up to two years after taper initiation.
“Given the observational study design, we cannot infer a causal connection between tapering and long-term risks of these events,” say the authors. “Nevertheless, our findings support guidelines advising careful monitoring and psychosocial support for patients undergoing opioid dose reduction and suggest that this support continue for at least two years after taper initiation, particularly among patients who were prescribed higher baseline doses.”
Over the past two decades, millions of Americans have been prescribed opioids to manage chronic pain. Although supported by limited evidence, medical educators encouraged the practice of initiating and escalating opioid dosages to address uncontrolled chronic pain, and drug companies aggressively marketed opioids, leading to increases in opioid prescriptions and the number of patients prescribed long-term opioid therapy (LTOT).
As opioid overdose deaths subsequently increased, state and regional policies have encouraged opioid deprescribing and dose reduction, or tapering, among patients prescribed LTOT. The frequency of tapering among patients increased substantially after publication of a Centers for Disease Control and Prevention (CDC) opioid prescribing guideline in 2016.
According to a US Department of Health and Human Services guideline, dose tapering in patients prescribed LTOT should be considered when the risks of dose continuation outweigh the benefits in terms of pain relief and functional improvement.
A dose-response association has been observed between long-term opioids and overdose risk, prompting the CDC to caution clinicians about escalating daily opioid doses greater than 50 morphine milligram equivalents. On the other hand, say the authors, opioid tapering may also confer patient risks, including precipitated withdrawal, worsening pain, use of illicit opioids, depression, anxiety, and suicide.
Importance: Research to date documenting tapering risks has generally examined periods near the time of initial dose reduction or discontinuation. This research, among patients prescribed long-term opioid therapy, highlights risks of substance misuse, overdose, and mental health crisis during the two years from initiation—when follow-up health care is needed. However, lowering opioid dosage can reduce risks of adverse events in the longer term.
Availability: Published by JAMA Network
