Higher proportion of overdose, tapering of opioids leading to mental health crisis

For patients receiving long-term opioid therapy, dose tapering was associated with an increased incidence of overdose, withdrawal, and mental health crises up to 2 years, claims-based studies found. did.

An analysis of approximately 20,000 patients who experienced opioid tapering between 2008 and 2017 showed that these dose reductions were associated with a 57% higher overdose or withdrawal rate 1-2 years after the onset of tapering. (Adjusted incidence ratio [aIRR] According to researchers led by Joshua Fenton, MD, MPH of the University of California, Davis in Sacramento, 1.57, 95% CI 1.42-1.74) compared to the pre-taper period.

The team also discovered a 40% higher overdose rate (aIRR 1.40, 95% CI 1.22-1.61) and a 52% higher mental health crisis rate (aIRR 1.52, 95% CI 1.35), especially during tapering or so-called post-induction periods. did. -1.71).

“Our findings suggest that for most tapering patients, overdose and an increased risk of mental health crisis can last up to two years after the onset of tapering,” Fenton and co-authors said. I am writing JAMA network..

Researchers say, “Patients may struggle during the tapering period, but many are stable with long-term follow-up, and many patients can be stable with a low incidence of overdose and mental health crises. The results were not what the group expected because they thought they were sexual, and the opioid dose was achieved. “

All patients included in the study initially had a stable opioid prescription (mean 50 morphine mg equivalent (MME) or higher for at least one year) before tapering began.

“Opioid weight loss is likely to hurt others while benefiting some,” wrote Dr. Stefan Kertesz and Dr. Allyson Varley of the University of Alabama at Birmingham. .. Ancillary editorial..

“Given this uncertain balance of harm and benefit, it would be wise to stop the healthcare system from promoting this change to care. The policy is to taper all patients to doses below the specified threshold. Cannot be supported by the available evidence, “they continued. “Quality indicators that encourage these policies, such as the high-dose opioid standards promulgated by the National Committee for Quality Assurance, have been postponed due to retirement.”

The duo said they urged experts who supported the CDC’s controversial 2016 opioid guidelines not to adopt this standard.

“If tapers fail, as many do, clinicians must be open to reversing them,” Kertesz and Varley added. “For this reason, the long-standing adage that opioid graduation should not be reversed, in most cases. Recently cited in a draft revision To [CDC]Opioid prescribing guidelines have been lightly worn by such studies and many previous studies. In our view, the maxim is not bound by clear and compelling evidence. I have to save it. “

Fenton’s group investigated 21,515 opioid tapering events involving 19,377 long-term opioid patients from 2008 to 2017. The patient came from the Optim Labs data warehouse.

Patients were included if followed for at least 1 month during the post-induction period (12 months after the start of tapering, defined as a 15% or greater reduction from the baseline dose). The average follow-up period for each taper event was 9.1 months.

The median age of patients was 56.9 years, more than half were women and 38.2% had commercial insurance. The baseline MME is:

• MME 50 ~ <90: 22.7%
• MME 90 ~ <150: 23.8%
• MME 150 ~ <300: 31.5%
• MME ≥ 300: 22.0%

The overdose / withdrawal rate was 3.5 per 100 man-years in the pre-taper period, but 5.4 per 100 man-years in the post-introduction period. In the case of overdose alone, these rates were 2.0 vs. 2.8, respectively, per 100 person-years. In the case of a mental health crisis defined as depression, anxiety, self-harm, or hospitalization or admission to the emergency department due to suicide attempt, the pre-taper period rate is 3.0 per 100 person-years and 4.4 per 100 person. did. Year after introduction.

Perhaps not surprisingly, all three results are more common in patients with the highest baseline MME, and a subgroup analysis based on dose initiation shows significant overdose / withdrawal events and mental health crisis events. An interaction was found.

Researchers have suggested that people undergoing tapering, especially those with high MME, will receive more support and supervision for up to two years.

Opioid doses decreased by an average of 39% during the post-introduction period (60 days). At this point, 15.2% discontinued opioids, 23.3% at 1-49% of baseline dose, 31.9% at 50-84% of baseline dose, and 1/4 at 85-114% of baseline dose. did. 4.7% had a dose increase of 115% or more.

Fenton’s group acknowledged the limits of comparison within the participants. This cannot explain the potential changes in the patient’s life from baseline. From the complaint data, it is unclear exactly why the patient lost weight. Potentially confounding variables adjusted for age, gender, educational status, rural residence, insurance status, baseline opioid prescriptions, existing anxiety and depression, and alcohol or substance abuse.