Tuesday, August 3, 2021

Opioid Tapering Associated With Increased Risks of Overdose, Mental Health Crises

Tapering patients’ opioid dose may increase their risk of overdose, withdrawal, and/or mental health crises, suggests a report published today in JAMA.

“The risks of long-term opioids are well documented, particularly at higher doses and in the presence of other risk factors for opioid toxicity, and clinicians and patients must carefully weigh risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy,” wrote Alicia Agnoli, M.D., M.P.H., of the University of California, Davis, and colleagues. “In the current study, tapering was associated with absolute differences in rates of overdose or mental health crisis events of approximately 3 to 4 events per 100 person-years compared with nontapering.”

Agnoli and colleagues analyzed administrative claims data from 113,618 patients aged 18 years or older who had been taking opioids (mean daily dose of at least 50 morphine mg equivalents) for at least 12 months. Beginning the first day after the end of the baseline year of stable dosing, patients were followed for up to one year. The authors compared emergency or hospital encounters for drug overdose or withdrawal and/or mental health crisis (depression, anxiety, suicide attempt) by patients who underwent opioid tapering with those who did not. They defined tapering as at least 15% relative reduction in mean daily dose during any of six overlapping 60-day windows.

A total of 18.2% of baseline periods were followed by tapering (37,170 tapering events). Patients who underwent tapering had significantly higher baseline opioid doses; were more likely to be co-prescribed benzodiazepines; and had significantly higher baseline rates of overdose, drug use disorder, depression, and anxiety.

The analysis revealed that post-tapering periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods. Additionally, tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years in nontapered periods. Patients undergoing a taper from higher baseline opioid doses and/or more rapid tapering were at a greater risk of these outcomes compared with those undergoing a taper from a lower baseline dose and/or a slower taper, the authors noted.

The authors described several limitations to the study, including that the analyses could not assess tapering circumstances or control for all factors that may have contributed to increased risk for adverse outcomes in the study population. “The risks associated with opioid tapering warrant further exploration to inform clinical guidelines regarding patient selection for tapering, optimal rates of dose reduction, and how best to monitor and support patients during periods of dose transition.”

“With caution in making any causal interpretations in mind, how should the findings reported by Agnoli et al influence the care of individuals receiving long-term opioid therapy?” asked Marc Larochelle, M.D., of Boston University School of Medicine and colleagues, in an accompanying editorial. “It is increasingly clear that opioid tapering needs to be approached with caution. In almost all cases, rapid or abrupt discontinuation should be avoided. Achieving the goals of minimizing risk yet also improving pain and function will require individualizing care and evidence-based approaches with more nuanced strategies that embrace the clinical complexity of the population of patients with chronic pain.”

For related information, see the Psychiatric News article “New HHS Guide on Opioid Tapering Encourages Collaboration.”

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