Abrupt Opioid Medication Dose Reductions Associated With Increased Mental Health and Substance Use-related Emergency Visits, While Modest Dose Reductions Are Not

Clinical guidelines have recommended limiting opioid medication doses for patients receiving long-term opioid therapy for chronic non-cancer pain. However, some studies have raised concerns about the safety of rapid or large dose reductions. This case-crossover study used linked primary care and hospital data from Victoria, Australia to examine whether changes in prescribed opioid dose were associated with subsequent mental health or substance use-related emergency department (ED) presentations. Adults with at least four opioid prescriptions in the prior year who later experienced a qualifying ED visit were included, allowing each individual to serve as their own control.

• Among 1458 individuals, 76 percent experienced an opioid dose reduction >25 percent in the 30 days preceding their ED visit.
• Compared with periods in which no opioid medications were prescribed, abrupt dose reductions (i.e., >25 percent) were associated with higher odds of mental health or substance use-related ED presentations (adjusted odds ratio [aOR], 1.78).
• Complete opioid medication discontinuation was also associated with increased risk of ED presentation (aOR, 2.04).
• In contrast, modest dose reductions (10–25 percent) were associated with a lower risk of ED presentation (aOR, 0.15). Stable or increased opioid dosing was associated with the lowest risk of ED presentation (aOR, 0.01).
• Findings were consistent across multiple control periods within individuals, strengthening causal inference and supporting a dose-response relationship.

Comments: This study underscores a critical distinction between intentional, patient-centered opioid de-prescribing and abrupt dose reduction. Large or rapid dose changes may destabilize patients, increasing psychological distress and acute care utilization rather than improving safety. For clinicians, these results reinforce the importance of shared decision-making, close follow-up, and tapering plans that are responsive to patient stability rather than externally imposed targets. At a systems level, policies or performance metrics that incentivize rapid opioid dose reductions without adequate clinical support may inadvertently increase downstream morbidity and emergency care use.

John Fomeche, MD* and Darius A. Rastegar, MD

*2025–26 Rich Saitz Editorial Intern & Addiction Medicine Fellow, Yale University

Reference: Jung M, Xia T, Picco L, et al. Change in prescription opioid dose and the risk of mental health-related and substance use-related emergency department presentations: a case-crossover study. Pain. 2026;167(4):767–775.