New evidence suggests that tapering the dosage in people receiving long-term opioid therapy may slightly increase the risk of overdose or suicide compared to stable-dose regimens.
In the results of a comparative efficacy trial including a cohort of 200,000 people, a team of American researchers reported that the gradual reduction and abrupt cessation of prescribed opioid doses are associated with a greater incidence of adverse events related to major substance use disorders. The data suggest that policies requiring a tapering off of long-term opioid regimens or strict duration limits on regimens may not be as beneficial as suggested.
The team led by Marc R. Larochelle, MD, MPH, of Boston University School of Medicine’s Clinical Addiction Research and Education Unit, sought to interpret the link between the progressive decrease opioids or abrupt discontinuation of opioids with risk of overdose and suicide in patients with no history. opioid abusers receive long-term stable prescription care. As they noted, the Centers for Disease Control and Prevention (CDC) released opioid prescribing guidelines for chronic pain in 2016 that recommended decreasing doses in cases where the benefits of addictive therapy do not help. outweighed its drawbacks.
Since the recommendation, it has become standard practice in various health care systems and in U.S. state legislation to enact “strict dose limits that have been enforced with few exceptions, regardless of the risk of harm to individual patients.” “. Thus, opioid prescribing and dosing rates have declined in the United States.
However, observational studies and systematic reviews have identified potential risks associated with the practice, albeit with limitations in the data and results.
“We sought to overcome these limitations by using data from a large claims database to compare the association of tapering opioids, abruptly stopping, or stable opioid treatment with overdose. or suicidal ideation or attempt in patients on stable long-term opioid doses without evidence of OUD or opioid abuse,” they wrote.
Larochelle and colleagues used a trial emulation strategy through a large national claims database to observe adult patients ≥ 18 years of age receiving long-term stable opioid therapy without evidence of abuse from 2010 to 2018. They compared the 3 dosing strategies of stable, abrupt cessation, or tapering—defined as a dose reduction of ≥15%.
The team defined the time to an opioid overdose or suicidal event according to ICD-9 and ICD-10 in medical claims data over 11 months of individual patient follow-up. Results were adjusted for baseline confounders.
The final cohort included 199,386 individuals; the average age was 56.9 years and the majority (57.6%) were between 45 and 64 years old. Another 45.1% were men. About a quarter (415,123) had qualifying long-term opioid treatment episodes; 87.1% was considered stable, 11.1% was considered reduction, and 1.8% was considered abrupt cessation.
Investigators observed a 0.96% cumulative incidence of opioid overdose or suicidal events in patients on a stable dose at 11 months (95% CI, 0.92 to 0.99), an incidence of 1 .10% in patients on reduced dose (95% CI, 0.99 to 1.22), and an incidence of 1.28% in patients on abrupt cessation (95% CI, 0.93 to 1, 38).
“We did not identify a difference in the risk of overdose or suicidal events between abrupt cessation and stable dosing, although the lower number of episodes classified as abrupt cessation may have reduced accuracy,” they wrote. they wrote. “The results were robust to secondary and sensitivity analyses.”
Although the data showed a more neutral association between tapering off opioids and the incidence of suicide or overdose compared to the previous trial, the investigators emphasized that this was not a ” protective association”. They concluded that the evidence does not support lowering opioid doses in an effort to reduce the risks of long-term harm from stable opioid therapies.
“Policies establishing dosage thresholds or mandating reductions for all patients receiving long-term opioid therapy are not supported by existing data in terms of anticipated benefits even though, as we have found, the rate of adverse effects is low,” Larochelle and colleagues wrote. “Health systems and clinicians must continue to develop and implement patient-centered approaches to pain management in patients on long-term opioid therapy.”
The study, “Comparative effectiveness of tapering or abruptly stopping opioids versus no dose modification for opioid overdose or suicide in patients on long-term stable opioid therapywas published online in Open JAMA Network.