High-Dose Opioid Tapering Linked to Overdose, Mental Health Crises
Patients tapered from a stable, long-term, higher-dose opioid therapy are significantly more likely to incur an overdose or a mental health crisis within one year, compared with those who are not tapered, according to a retrospective cohort study.
“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,” said principal investigator Alicia Agnoli, MD, MPH, MHS, an assistant professor of family and community medicine at the University of California, Davis, in Sacramento. “However, there have been reports of patients becoming suicidal as their doses were reduced, as well as overdose events.”
The study culled deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the United States prescribed stable higher doses of opioids, defined as a mean 50 morphine milligram equivalents per day for a 12-month baseline period with at least two months of follow-up, were eligible for inclusion. Opioid tapering was designated as at least a 15% relative reduction in mean daily dose during any of six overlapping 60-day windows within a seven-month follow-up period.
The two main outcomes were emergency or hospital encounters for drug overdose or withdrawal, and mental health crises such as depression, anxiety and suicide attempt, during the first 12 months of follow-up. The final study cohort consisted of 113,618 patients, of whom 18.2% underwent dose tapering. Patients who did and did not undergo dose tapering were matched for age, sex and insurance type (women, taper 54.3% vs. no taper 53.2%; age, taper 57.7 vs. no taper 58.3 years; commercially insured, taper 38.8% vs. no taper 41.9%).
Tapered patients were found to be more highly associated with overdose, 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 patients. The same was true for experiencing a mental health crisis, where tapered patients had an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years versus 3.3 events per 100 person-years in nontapered patients.
Furthermore, increasing the maximum monthly dose reduction by 10% was connected to an adjusted incidence rate ratio of 1.09 for overdose and 1.18 for mental health crisis.
Dr. Agnoli and her research team are troubled by the magnitude of the associations they found. “For every 100 patients followed for one year, tapering was connected to about four additional patients having an overdose event and four additional patients having a mental health crisis event,” Dr. Agnoli said. “Because we only looked at hospital and emergency events, this could be just the tip of the iceberg of suffering that patients experience when tapering.”
Clinicians need to understand that the period of tapering is one of heightened vulnerability, Dr. Agnoli said. “The decision to embark on tapering should depend on the patient’s goals and priorities. Also, when possible, the rate of dose reduction should be gradual.”
Dr. Agnoli believes clinicians should try to schedule patients frequently and be on the lookout for symptoms of withdrawal, worsening pain and/or depression. She also encourages medical practices to implement the recommendations outlined in the recent Health and Human Services guideline for opioid dose reduction, released in October 2019.
“Opioid therapy is complex, with important risk–benefit considerations for patients and prescribers alike,” she said. “Our study sheds light on specific and significant risks associated with the complicated endeavor of deprescribing. We hope the study will inform a more cautious and compassionate approach to decisions around opioid dose tapering.”
Due to the increased risk for overdose and mental health crisis following dose reduction, “patients undergoing tapering need significant support to safely reduce or discontinue their opioids,” Dr. Agnoli added.
Jeffrey C. Gadsden, MD, FRCPC, FANZCA, the chief of the Division of Orthopaedics, Plastics and Regional Anesthesiology and an associate professor of anesthesiology at Duke University, in Durham, N.C., noted that the study results “support some other evidence to date, suggesting that the psychologic strain o f rapid tapering, especially from high baseline doses, can precipitate mental health crises or accidental overdose.”
However, the conclusions should be interpreted with some caution, said Dr. Gadsden, who was not part of the research, “particularly because its particular methodology used patients who presented to the hospital with either overdose or mental health crisis.”
Dr. Gadsden said he suspects the data would look somewhat different if the study had included patients in each cohort who succumbed to overdose or suicide attempt at home, “which is a more alarming outcome.”
Regardless, the study “serves as a good reminder that opioid tapering—a noble and worthwhile goal—should only be attempted with the appropriate support structure in place to ensure patient safety and compliance,” he said. “The study also underscores the notion that preventive strategies remain our best weapon against opioid-related morbidity and mortality. Every effort should be made by physicians to provide patients with a variety of nonopioid analgesic strategies and therapies before moving on to prescribing opioids.”
Filed under: General Problems
Well insufferable pain is not a “mental health crisis”, anyone would start babbling insensibly… It’s a coward doctor crisis.