Stable, Long-term Opioid Therapy Safer Than Tapering?

https://flashnews11.com/health/medicine/stable-long-term-opioid-therapy-safer-than-tapering/

Discontinuing secure, long-term opioid remedy is probably not obligatory for sufferers who present no indicators of misuse ― and it may even be safer than tapering or abrupt discontinuation, new analysis suggests.

Investigators analyzed knowledge for nearly 200,000 sufferers who didn’t have indicators of opioid use dysfunction (OUD) and have been receiving opioid remedy. The investigators in contrast three dosing methods: abrupt withdrawal, gradual tapering, and continuation of the present secure dosage.

Results confirmed a better adjusted cumulative incidence of opioid overdose or suicide occasions 11 months after baseline amongst members for whom a tapered dosing technique was utilized, in contrast with those that continued taking a secure dosage. The danger distinction was 0.15% between taper and secure dosage and 0.33% between abrupt discontinuation and secure dosage.

“This study identified a small absolute increase in risk of harms associated with opioid tapering compared with a stable opioid dosage,” Mark LaRochelle, MD, assistant professor of drugs, Boston University School of Medicine, Massachusetts, and colleagues write.

“These results do not suggest that policies of mandatory dosage tapering for individuals receiving a stable long-term opioid dosage without evidence of opioid misuse will reduce short-term harm via suicide and overdose,” they add.

The findings have been published online August 12 in JAMA Network Open.

Benefits vs Harms

The investigators word that the Centers for Disease Control and Prevention (CDC), in its 2016 Guideline for Prescribing Opioids for Chronic Pain, “recommended tapering opioid dosages if benefits no longer outweigh harms.”

In response, “some health systems and US states enacted stringent dose limits that were applied with few exceptions, regardless of individual patients’ risk of harms,” they write. By distinction, there have been “increasing reports of patients experiencing adverse effects from forced opioid tapers.”

Previous research that recognized harms related to opioid tapering and discontinuation had a number of limitations, together with a give attention to discontinuation, which is “likely more destabilizing than gradual tapering,” the researchers write. There can be “a high potential for confounding” in these research, they add.

The investigators sought to fill the analysis hole by drawing on 8-year knowledge (January 1, 2020, to December 31, 2018) from a big database that features adjudicated pharmacy, outpatient, and inpatient medical claims for people with business or Medicare Advantage insurance coverage encompassing all 50 states, the District of Columbia, and Puerto Rico.

Notably, people who had obtained a prognosis of substance use, abuse, or dependence or for whom there have been indicators in line with OUD have been excluded.

The researchers in contrast the three remedy methods throughout a 4-month remedy technique project interval (“grace period”) after baseline. Tapering was outlined as “2 consecutive months with a imply MME [ morphine milligram equivalent] discount of 15% or extra in contrast with the baseline month.”

All estimates have been adjusted for potential confounders, together with demographic and remedy traits, baseline yr, area, insurance coverage plan kind, comorbid psychiatric and medical situations, and the prescribing of different psychiatric medicines, corresponding to benzodiazepines, gabapentin, or pregabalin.

Patient-Centered Approaches

The remaining cohort that met inclusion standards consisted of 199,836 people (45.1% males; imply age, 56.9 years). Of the overall group, 57.6% have been aged 45–64 years. There have been 415,123 qualifying long-term opioid remedy episodes.

The largest share of the cohort (41.2%) have been receiving a baseline imply MME of fifty – 89 mg/day, whereas 34% have been receiving 90 – 199 mg/day and 23.5% have been receiving no less than 200 mg/day.

During the 6-month eligibility evaluation interval, 34.8% of the cohort have been receiving benzodiazepine prescriptions, 18% had been recognized with comorbid anxiousness, and 19.7% had been recognized with comorbid depression.

After the remedy project interval, most remedy episodes (87.1%) have been thought of secure, 11.1% have been thought of a taper, and 1.8% have been thought of abrupt discontinuation.

Eleven months after baseline, the adjusted cumulative incidence of opioid overdose or suicide occasions was lowest for many who continued to obtain a secure dose.

Dose technique	Adjusted cumulative incidence of overdose or suicide (95% CI)
Stable	0.96% (0.92% – 0.99%)
Tapered	1.10% (0.99% – 1.22%)
Abrupt discontinuation	1.28% (0.93% – 1.38%)

 

The danger variations between taper vs secure dosage have been 0.15% (95% CI, 0.03% – 0.26%), and the danger variations between abrupt discontinuation and secure dose have been 0.33% (95% CI, −0.03% to 0.74%). The danger ratios related to taper vs secure dosage and abrupt discontinuation vs secure dosage have been 1.15 (95% CI, 1.04 – 1.27) and 1.34 (95% CI, .97 – 1.79), respectively.

The adjusted cumulative incidence curves for overdose or suicide diverged at month 4 when evaluating secure dosage and taper, with a better incidence related to the taper vs secure dosage remedy methods thereafter. However, when the researchers in contrast secure dosage with abrupt discontinuation, the occasion charges have been related.

A per protocol evaluation, wherein the researchers censored episodes involving lack of adherence to assigned remedy, yielded outcomes just like these of the primary evaluation.

“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,” the investigators write.

Instead, they encourage healthcare techniques and clinicians to “continue to develop and implement patient-centered approaches to pain management for patients with established long-term opioid therapy.”

Protracted Withdrawal?

Commenting for Medscape Medical News, A. Benjamin Srivastava, MD, assistant professor of scientific psychiatry, Division on Substance Use Disorders, Columbia University Medical Center, New York State Psychiatric Institute, New York City, known as the examine “an important contribution to the literature” that “sheds further light on the risks associated with tapering.”

Srivastava, who was not concerned with the analysis, famous that earlier research exhibiting an elevated prevalence of antagonistic occasions with tapering included members with OUD or indicators of opioid misuse, “potentially confounding findings.”

By distinction, the present examine investigators particularly excluded sufferers with OUD/opioid misuse however nonetheless discovered a “slight increase in risk for opioid overdose and suicide, even when excluding for potential confounders,” he mentioned.

Although causal implications require additional investigation, “a source of these adverse outcomes may be unmanaged withdrawal that may be protracted,” Srivastava famous.

While abrupt discontinuation “may result in significant acute withdrawal symptoms, these should subside by 1–2 weeks at most,” he mentioned.

Lowering the dose with out discontinuation might result in sufferers’ getting into into “a dyshomeostatic state characterized by anxiety and dysphoria…that may not be recognized by the prescribing clinician,” he added.

The mind “is still being primed by opioids [and] ‘wanting’ a higher dose. Thus, particular attention to withdrawal symptoms, both physical and psychiatric, is prudent when choosing to taper opioids vs maintaining or discontinuing,” Srivastava mentioned.

The examine was funded by a grant from the CDC and a grant from the National Institute on Drug Abuse (NIDA) to one of many investigators. LaRochelle obtained grants from the CDC and the NIDA through the conduct of the examine and has obtained consulting charges for analysis paid to his establishment from OptumLabs outdoors the submitted work. The different investigators’ disclosures are listed within the unique article. Srivastava stories no related monetary relationships.

JAMA Netw Open. Published on-line August 12, 2022. Full article

Batya Swift Yasgur, MA, LSW, is a contract author with a counseling observe in Teaneck, NJ. She is an everyday contributor to quite a few medical publications, together with Medscape and WebMD, and is the creator of a number of consumer-oriented well being books in addition to Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two courageous Afghan sisters who advised her their story).

 

Filed under: General Problems