Does reducing the dose for patients on stable opioid therapy have long-term overdose and mental health risks?
Researchers at the UC Davis Center for Health Policy and Research looked at the potential long-term risks of reducing opioid doses. Stable but higher-dose opioid therapy decreased the dose by at least 15% in the second year after overdose and had significantly higher rates of mental health crisis compared to the previous reduction period.
Their review was published on June 13th JAMA network open.
Opioid therapy and a push to reduce the dose of pain medication
Changes in prescribing guidelines and regulations driven by the rise in opioid-related deaths have led many physicians to reduce daily doses for patients with stable opioid therapy for chronic pain. The process of dose reduction – called tapping – has been linked to some patients with worsening pain, opioid withdrawal symptoms, and depressed mood.
Recently, a team of UC Davis Health researchers found that overdose and increased risk of a mental health crisis increased up to one year after the dose was reduced. Their research suggests that patients with restriction need significant support to safely reduce or discontinue opioids.
“While patients may struggle during the downsizing period, many reasoned that they can stabilize with longer-term follow-up and have a lower dose of opioid overdose and have lower rates of mental health crisis,” said Joshua Fenton, assistant professor. Head of Research and Chief Research Officer in the Department of Family and Community Medicine at UC Davis School of Medicine. “Our findings suggest that, for most patients at a lower level, the risks of an overdose and mental health crisis persist for up to two years after starting to be reduced.”
Pain management and risk of dose adjustment
To draw the relationship between dose reduction and overdose and changes in mental health visit risk, the researchers used a database over 10 years (2008-2017) for more than 28,000 long-term opioid-prescribed patients. They looked at steady doses of opioids (equivalent to at least 50 milligrams of morphine per day) and reduced enrollment records and medical and pharmaceutical claims for patients who reduced their doses by at least 15%.
From this cohort of patients, those who had a follow-up of at least one month in the second year after the fall were selected. A total of 21,515 tapering events were identified for 19,377 patients.
These events included emergency department visits or hospital admissions for drug overdoses, withdrawal, or mental health crises such as depression, anxiety, or suicide attempts. The group compared the rates of these events in the period prior to the decrease with the second year of follow-up following the onset of the decrease.
“We used an innovative observational study design to understand the patient experience before and after reducing opioid doses. We compared pre-Taper and postoperative outcome rates with patients as their control,” said author Daniel Tancredi. research and professor in the Department of Pediatrics at UC Davis Health. “This design has the advantage of controlling the characteristics of patients that can affect the relationship between tapering and adverse events.”
The study found that there were an average of 3.5 overdose or withdrawal events per 100 patients and 3 mental health crises in the pre-reduction period, compared to 5.4 events and 4.4 seizures in the 12-24-month fall period. This is an increase of 57% in cases of overdose or abstinence and a 52% increase in mental health crises. The highest risk of reduction in patients with the highest baseline doses was greatest.
“We have seen an increase in overdose rates and mental health crises seen in the first year after the opioid dose reduction,” Fenton added.
Long-term follow-up and support for patients in pain reduction therapy
In 2018, the Department of Health and Human Services (HHS) issued guidelines advising physicians to monitor patients carefully and provide psychosocial support. They recommended close monitoring and warned of potential risks of rapid dose reduction, such as withdrawal, transition to illegal opioids, and psychological distress.
This new study highlighted the need for clinicians and patients to discuss dose reduction and carefully measure the risks and benefits of opioid monitoring and reduction. Tapered patients should have close follow-up and monitoring not only in the short term but also in the long term to ensure that they are doing well with lower doses.
“We hope this work will provide a more cautious view of decisions about opioid dose reduction,” Fenton said. “Although our results suggest that all lower-level patients may benefit from follow-up and support up to two years after the discontinuation, patients prescribed higher doses may benefit from more intensive support and follow-up, particularly depression and suicide.”
Other UC Davis Health contributors include Elizabeth Magnan, Iraklis Erik Tseregounis, Guibo Xing and Alicia Agnoli. The research was supported by a research credit from the University of California-OptumLabs, the Department of Family and Community Medicine at UC Davis and the Dean’s Office of the UC Davis School of Medicine (Dean’s Scholarship in Women’s Health Research BIRCWH / K12).