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Long-Term Opioid Tapering Does Not Benefit Suicide, Overdose Risks

New comparative effectiveness data go against CDC recommendations for tapering or abruptly ending long-term opioid prescription.

Dosage tapering for persons receiving long-term opioid treatment may slightly increase risk of overdose or suicide compared to stable-dose regimens, according to new data.

In findings from a comparative effectiveness trial including a cohort of 200,000 individuals, a team of US investigators reported that both tapering and abruptly discontinuing prescribed opioid doses are associated with greater incidence of major use disorder-related adverse events. The data suggest policies requiring tapering of long-term opioid regimens or hard duration limits on regimens may not be as beneficial as suggested.

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The team led by Marc R. Larochelle, MD, MPH, of the clinical addiction research and education unit of the Boston University School of Medicine, sought to interpret the link between opioid tapering or abrupt discontinuation with risk of overdose and suicides among patients without history of opioid misuse receive stable long-term prescription care. As they noted, the Centers for Disease Control and Prevention (CDC) released chronic pain opioid prescription guidelines in 2016 that recommended tapering dosages in instances when the addictive therapy’s benefits no longer outweighed its harms.

Since the recommendation, it’s become a common practice in various health systems and in US state legislation to enact “stringent dose limits that were applied with few exceptions regardless of individual patients’ risk of harms.” As such, opioid prescribing and dosage rates declined in the US.

However, observational studies and systematic reviews have identified potential risks associated with the practice—albeit with limitations in data and outcomes.

“We sought to overcome these limitations using data from a large claims database to compare the association of opioid tapering, abrupt discontinuation, or stable opioid therapy with opioid overdose or suicidal ideation or attempt among patients receiving stable long-term opioid dosages without signs of OUD or opioid misuse,” they wrote.

Larochelle and colleagues used a trial emulation strategy through a large national claims database to observe adult patients ≥18 years old receiving stable long-term opioid therapy without evidence of misuse from 2010 - 2018. They compared the 3 dosing strategies of stable dosing, abrupt discontinuation, or tapering—defined as a dosage reduction of ≥15%.

The team defined time to opioid overdose or suicide event per ICD-9 and ICD-10 in the medical claims data over 11 months of individual patient follow-up. Outcomes were adjusted for baseline confounders.

The final cohort included 199,386 individuals; mean age was 56.9 years old and a majority (57.6%) were aged 45-64 years old. Another 45.1% were men. Approximately one-quarter (415,123) had qualifying long-term opioid therapy episodes; 87.1% were considered stable, 11.1% were considered a taper, and 1.8% were considered an abrupt discontinuation.

Investigators observed a cumulative 0.96% incidence of opioid overdose or suicide events among stable-dose patients at 11 months (95% CI, 0.92 – 0.99), a 1.10% incidence among tapered-dose patients (95% CI, 0.99 – 1.22), and a 1.28% incidence among abrupt-discontinuation patients (95% CI, 0.93 – 1.38).

“We did not identify a difference in the risk of overdose or suicide events between abrupt discontinuation and stable dosage, although the smaller number of episodes categorized as abrupt discontinuation may have reduced precision,” they wrote. “The findings were robust to secondary and sensitivity analyses.”

While the data showed a more neutral association of opioid tapering with suicide or overdose incidence relative to previous trial, investigators stressed it was not a “protective association.” They concluded that evidence does not support tapering opioid dosages for the goal of reducing long-term stable opioid therapy harm risks.

“Policies establishing dosage thresholds or mandating tapers for all patients receiving long-term opioid therapy are not supported by existing data in terms of anticipated benefits even if, as we found, the rate of adverse outcomes is small,” Larochelle and colleagues wrote. “Health systems and clinicians must continue to develop and implement patient-centered approaches to pain management for patients with established long-term opioid therapy.”

The study, “Comparative Effectiveness of Opioid Tapering or Abrupt Discontinuation vs No Dosage Change for Opioid Overdose or Suicide for Patients Receiving Stable Long-term Opioid Therapy,” was published online in JAMA Network Open.