Prescribed Opioid Medication Discontinuation or Rapid Dose Decrease Associated With Subsequent Overdose

The increase in opioid prescribing for chronic pain that started in the early 1990s led to an increase in overdose and opioid use disorder (OUD). In response to this, there have been efforts to decrease initial opioid prescribing, as well as decreasing or discontinuing opioid medications among patients receiving them for chronic pain. This study used data from a US private health insurer to identify individuals who received high-dose, long-term opioid therapy (HDLTOT, defined as ≥90 morphine milligram equivalents/day for ≥90% of 90 consecutive days), and to investigate the association between rapid discontinuation (defined as >10% dose reduction within a week or 34% within a month) and subsequent overdose or diagnosis of OUD.

• There were 19,443 enrollees who received HDLTOT. During a follow-up period of up to 4 years, there were 59 fatal opioid overdoses, 215 nonfatal overdoses, and 2796 incident OUD diagnoses.
• Rapid reduction or discontinuation of opioid medication was associated with an increased risk of fatal and nonfatal overdoses compared with dose maintenance or gradual reduction (year 1 weighted hazard ratio (HR) was 1.43 and year 2–4 was 1.95).
• Rapid reduction was not associated with an incident diagnosis of OUD in the first 2 years (HR, 1.01), but was 25–48 months afterwards (HR, 1.28).

Comments: This study suggests that rapid dose decreases or discontinuation of opioid medications among people who are prescribed them may lead to harms. We do not know the reasons behind the rapid dose reductions in this cohort; the observed association may be at least partly due to clinicians being more likely to do this with higher-risk patients. In any case, we should continue to avoid initiating opioids for chronic pain and to treat those who are already taking opioid medications in a patient-centered manner that avoids drastic and arbitrary changes.

Darius A. Rastegar, MD

Reference: DiPrete BL, Ranapurwala SI, Maierhofer CN, et al. Association of opioid dose reduction with opioid overdose and opioid use disorder among patients receiving high-dose, long-term opioid therapy in North Carolina. JAMA Netw Open. 2022;5(4):e229191.