Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017

How Racialized Approaches to Opioid Use Disorder and Opioid Misuse Management Hamper Pharmacoequity for Cancer Pain

@JCO_ASCO paper focuses on racialized approaches to OUD and opioid misuse as underappreciated drivers of disparities in cancer and recs a path forward.

"Saving us to Death": Ideology and Communicative (Dis)enfranchisement in Misapplications of the 2016 CDC Opioid Prescribing Guidelines

Guided by the theory of communicative (dis)enfranchisement (TCD), this study interrogates how interactions in which chronic pain patients are force tapered from their prescribed opioids are constrained and afforded by the hegemonic ideologies. To interrogate the harms caused for chronic pain patients by ideological policies enacted by the Centers for Disease Control and Prevention and assess what communicative mechanisms reify and resist such ideologies, this research analyzes 238 posts authored by chronic pain patient Reddit users. Reflexive thematic analysis illuminated a hegemonic ideology of opiophobia, (im)material ramifications of (a) discrimination by doctors, and (b) political and legal interference; mechanisms of reification: (a) positioning suicide as a rational option, (b) advocating for the use of illicit substances, and (c) stopping opioids voluntarily; and mechanisms of resistance: (a) counter-organizing and (b) counter-generating knowledge. We offer theoretical implications for the TCD and practical implications for patients, providers, patient advocacy organizations, and policymakers.

Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain

ABSTRACT

Current research indicates that tapering opioids may improve pain and function in patients with chronic noncancer pain. However, gaps in the literature remain regarding the choice of opioid and nonopioid interventions to support a successful taper. This study used an Australian primary care data set to identify a cohort of patients on long-term opioid therapy commencing opioid taper between January 2016 and September 2019. Using logistic regression analysis, we compared key clinical factors associated with differing taper outcomes. Of a total of 3371 patients who commenced taper, 1068 (31.7%) completed taper within 12 months. In the 3 months after commencement of taper, compared with those who did not complete taper, patients who successfully completed opioid taper were less likely to be prescribed buprenorphine (odds ratio [OR] 0.691; 95% CI: 0.530-0.901), fentanyl (OR, 0.429; 95% CI: 0.295-0.622), and long-acting (LA) opioids, including methadone (OR, 0.349; 95% CI: 0.157-0.774), oxycodone-naloxone (OR, 0.521; 95% CI: 0.407-0.669), and LA tapentadol (OR, 0.645; 95% CI: 0.461-0.902), but more likely to be prescribed codeine (OR, 1.308; 95% CI: 1.036-1.652). Compared with those who did not complete taper, patients who successfully tapered were less likely to be prescribed any formulations of oxycodone (short-acting [SA]: OR, 0.533; 95% CI: 0.422-0.672, LA: OR, 0.356; 95% CI: 0.240-0.530) and tramadol (SA: OR, 0.370; 95% CI: 0.218-0.628, LA: OR, 0.317; 95% CI: 0.234-0.428). The type of opioid prescribed in the months after commencement of taper seems to influence the taper outcomes. These findings may inform prospective studies on opioid taper.

Clinical and healthcare use outcomes after cessation of long term opioid treatment due to prescriber workforce exit: quasi-experimental difference-in-differences study

OBJECTIVE

To examine the association between prescriber workforce exit, long term opioid treatment discontinuation, and clinical outcomes.

DESIGN

Quasi-experimental difference-in-differences study SETTING: 20% sample of US Medicare beneficiaries, 2011-18.

PARTICIPANTS

People receiving long term opioid treatment whose prescriber stopped providing office based patient care or exited the workforce, as in the case of retirement or death (n=48 079), and people whose prescriber did not exit the workforce (n=48 079).

MAIN OUTCOMES

Discontinuation from long term opioid treatment, drug overdose, mental health crises, admissions to hospital or emergency department visits, and death. Long term opioid treatment was defined as at least 60 days of opioids per quarter for four consecutive quarters, attributed to the plurality opioid prescriber. A difference-in-differences analysis was used to compare individuals who received long term opioid treatment and who had a prescriber leave the workforce to propensity-matched patients on long term opioid treatment who did not lose a prescriber, before and after prescriber exit.

RESULTS

Discontinuation of long term opioid treatment increased from 132 to 229 per 10 000 patients who had prescriber exit from the quarter before to the quarter after exit, compared with 97 to 100 for patients who had a continuation of prescriber (adjusted difference 1.22 percentage points, 95% confidence interval 1.02 to 1.42). In the first quarter after provider exit, when discontinuation rates were highest, a transient but significant elevation was noted between the two groups of patients in suicide attempts (adjusted difference 0.05 percentage points (95% confidence interval 0.01 to 0.09)), opioid or alcohol withdrawal (0.14 (0.01 to 0.27)), and admissions to hospital or emergency department visits (0.04 visits (0.01 to 0.06)). These differences receded after one to two quarters. No significant change in rates of overdose was noted. Across all four quarters after prescriber exit, an increase was reported in the rate of mental health crises (0.39 percentage points (95% confidence interval 0.08 to 0.69)) and opioid or alcohol withdrawal (0.31 (0.014 to 0.58)), but no change was seen for drug overdose (-0.12 (-0.41 to 0.18)).

CONCLUSIONS

The loss of a prescriber was associated with increased occurrences of discontinuation of long term opioid treatment and transient increases in adverse outcomes, such as suicide attempts, but not other outcomes, such as overdoses. Long term opioid treatment discontinuation may be associated with a temporary period of adverse health impacts after accounting for unobserved confounding.

Prescription Opioid Dose Reductions and Potential Adverse Events: a Multi-site Observational Cohort Study in Diverse US Health Systems

BACKGROUND

In response to the opioid crisis in the United States, population-level prescribing of opioids has been decreasing; there are concerns, however, that dose reductions are related to potential adverse events.

OBJECTIVE

Examine associations between opioid dose reductions and risk of 1-month potential adverse events (emergency department (ED) visits, opioid overdose, benzodiazepine prescription fill, all-cause mortality).

DESIGN

This observational cohort study used electronic health record and claims data from eight United States health systems in a prescription opioid registry (Clinical Trials Network-0084). All opioid fills (excluding buprenorphine) between 1/1/2012 and 12/31/2018 were used to identify baseline periods with mean morphine milligram equivalents daily dose of  ≥ 50 during six consecutive months.

PATIENTS

We identified 60,040 non-cancer patients with  ≥ one 2-month dose reduction period (600,234 unique dose reduction periods).

MAIN MEASURES

Analyses examined associations between dose reduction levels (1- < 15%, 15- < 30%, 30- < 100%, 100% over 2 months) and potential adverse events in the month following a dose reduction using logistic regression analysis, adjusting for patient characteristics.

KEY RESULTS

Overall, dose reduction periods involved mean reductions of 18.7%. Compared to reductions of 1- < 15%, dose reductions of 30- < 100% were associated with higher odds of ED visits (OR 1.14, 95% CI 1.10, 1.17), opioid overdose (OR 1.41, 95% CI 1.09-1.81), and all-cause mortality (OR 1.39, 95% CI 1.16-1.67), but lower odds of a benzodiazepine fill (OR 0.83, 95% CI 0.81-0.85). Dose reductions of 15- < 30%, compared to 1- < 15%, were associated with higher odds of ED visits (OR 1.08, 95% CI 1.05-1.11) and lower odds of a benzodiazepine fill (OR 0.93, 95% CI 0.92-0.95), but were not associated with opioid overdose and all-cause mortality.

CONCLUSIONS

Larger reductions for patients on opioid therapy may raise risk of potential adverse events in the month after reduction and should be carefully monitored.

Trajectories of prescription opioid tapering in patients with chronic non-cancer pain: a retrospective cohort study, 2015-2020

OBJECTIVE

To identify common opioid tapering trajectories among patients commencing opioid taper from long-term opioid therapy for chronic non-cancer pain and to examine patient-level characteristics associated with these different trajectories.

DESIGN

A retrospective cohort study.

SETTING

Australian primary care.

SUBJECTS

Patients prescribed opioid analgesics between 2015 and 2020.

METHODS

Group-based trajectory modeling and multinomial logistic regression analysis were conducted to determine tapering trajectories and to examine demographic and clinical factors associated with the different trajectories.

RESULTS

A total of 3369 patients commenced a taper from long-term opioid therapy. Six distinct opioid tapering trajectories were identified: low dose / completed taper (12.9%), medium dose / faster taper (12.2%), medium dose / gradual taper (6.5%), low dose / noncompleted taper (21.3%), medium dose / noncompleted taper (30.4%), and high dose / noncompleted taper (16.7%). A completed tapering trajectory from a high opioid dose was not identified. Among patients prescribed medium opioid doses, those who completed their taper were more likely to have higher geographically derived socioeconomic status (relative risk ratio [RRR], 1.067; 95% confidence interval [CI], 1.001-1.137) and less likely to have sleep disorders (RRR, 0.661; 95% CI, 0.463-0.945) than were those who didn't complete their taper. Patients who didn't complete their taper were more likely to be prescribed strong opioids (eg, morphine, oxycodone), regardless of whether they were tapered from low (RRR, 1.444; 95% CI, 1.138-1.831) or high (RRR, 1.344; 95% CI, 1.027-1.760) doses.

CONCLUSIONS

Those prescribed strong opioids and high doses appear to be less likely to complete tapering. Further studies are needed to evaluate the clinical outcomes associated with the identified trajectories.

Older Adult and Primary Care Practitioner Perspectives on Using, Prescribing, and Deprescribing Opioids for Chronic Pain

Importance

Guidelines recommend deprescribing opioids in older adults due to risk of adverse effects, yet little is known about patient-clinician opioid deprescribing conversations.

Objective

To understand the experiences of older adults and primary care practitioners (PCPs) with using opioids for chronic pain and discussing opioid deprescribing.

Design, Setting, and Participants

This qualitative study conducted semistructured individual qualitative interviews with 18 PCPs and 29 adults 65 years or older prescribed opioids between September 15, 2022, and April 26, 2023, at a Boston-based academic medical center. The PCPs were asked about their experiences prescribing and deprescribing opioids to older adults. Patients were asked about their experiences using and discussing opioid medications with PCPs.

Main Outcome and Measures

Shared and conflicting themes between patients and PCPs regarding perceptions of opioid prescribing and barriers to deprescribing.

Results

In total, 18 PCPs (12 [67%] younger that 50 years; 10 [56%] female; and 14 [78%] based at an academic practice) and 29 patients (mean [SD] age, 72 [5] years; 19 [66%] female) participated. Participants conveyed that conversations between PCPs and patients on opioid use for chronic pain were typically challenging and that conversations regarding opioid risks and deprescribing were uncommon. Three common themes related to experiences with opioids for chronic pain emerged in both patient and PCP interviews: opioids were used as a last resort, opioids were used to improve function and quality of life, and trust was vital in a clinician-patient relationship. Patients and PCPs expressed conflicting views on risks of opioids, with patients focusing on addiction and PCPs focusing on adverse drug events. Both groups felt deprescribing conversations were often unsuccessful but had conflicting views on barriers to successful conversations. Patients felt deprescribing was often unnecessary unless an adverse event occurred, and many patients had prior negative experiences tapering. The PCPs described gaps in knowledge on how to taper, a lack of clinical access to monitor patients during tapering, and concerns about patient resistance.

Conclusions and Relevance

In this qualitative study, PCPs and older adults receiving long-term opioid therapy viewed the use of opioids as a beneficial last resort for treating chronic pain but expressed dissonant views on the risks associated with opioids, which made deprescribing conversations challenging. Interventions, such as conversation aids, are needed to support collaborative discussion about deprescribing opioids.

Incidence and Prevalence of Pain Medication Prescriptions in Pathologies with a Potential for Chronic Pain

BACKGROUND

Heightened risks of dependence, addiction, anxiolytic effects, or prescription overdose death due to long-term use of pain medication have increased awareness about extended pain medication use in chronic pain populations. The goal of this study was to evaluate the incidence and prevalence of pain medication prescriptions from 2012 to 2022 in common pathologies with a potential for chronic pain.

METHODS

A retrospective cohort study was conducted using electronic health records from TriNetX (Cambridge, Massachusetts) Global Collaborative Network. For 10 distinct cohorts (total n = 9,357,584 patients), pain medication prescriptions were extracted for five classes, namely nonsteroidal anti-inflammatory drug (NSAIDs) and acetaminophen, opioids, gabapentinoids, neuropathic mood agents, and muscle relaxants. Annual incidence and prevalence of each class of medication were evaluated for the past 11 yr.

RESULTS

From 2012 to 2022, there was a significant increase in prescriptions of NSAIDs, except for patients with fibromyalgia, and persistent spinal pain syndrome (PSPS) type 2. Interestingly, over time, prescriptions of opioids in patients with complex regional pain syndrome, endometriosis, osteoarthritis, and PSPS type 2 increased, as did prescriptions of muscle relaxants for all cohorts except those with fibromyalgia. Incidence of prescriptions of neuropathic mood agents is high for patients with complex regional pain syndrome (both types) and PSPS type 2. Only for benzodiazepines did there seem to be a decline over the years, with a significantly decreased time trend in patients with complex regional pain syndrome type 1, fibromyalgia, and PSPS type 2.

CONCLUSIONS

During the last 11 yr, an increase in incidence of NSAIDs and acetaminophen, opioids, neuropathic agents, and muscle relaxants was observed. Only prescriptions of benzodiazepines significantly decreased over time in specific cohorts. Overall, patients with PSPS type 2 and complex regional pain syndrome (both types) consume a broad variety of pain medication classes.

EDITOR’S PERSPECTIVE

Opioid tapering and mental health crisis in older adults

BACKGROUND

Opioid tapering and discontinuation have increased in recent years with the implementation of national prescribing guidelines. This study aimed to examine the relationship between opioid tapering velocity and mental health crisis events in older Medicare beneficiaries.

METHODS

A nested case-control study was conducted using the 2012-2018, 5% national Medicare claims data. Older adults with chronic non-cancer pain (CNCP) who were receiving long-term opioid therapy (LTOT) were included in the study. Cases were defined as individuals experiencing mental health crisis events; controls were identified using incidence density sampling. The opioid tapering velocity was measured in the 120-day hazard period that yielded a monthly percentage of dose change. Conditional logistic regression was used to assess the relationship of interest.

RESULTS

A total of 42 091 older adults with CNCP were eligible for the study. Cases (n = 952) were matched with controls in a 1:2 ratio based on age (±1 year) and time of cohort entry (±30 days). A higher percentage of controls (67.65%) were on steady dose compared with cases (59.03%). In the adjusted model, tapering (aOR = 1.36; 95% CI: 1.02-1.83), rapid tapering (aOR = 1.45; 95% CI: 1.11-1.91), and dose escalation (aOR = 1.78; 95% CI: 1.32-2.39) were significantly associated with the mental health crisis, compared with steady dose.

CONCLUSION

Both opioid tapering and dose escalation are associated with mental health crisis events. Patient-driven and gradual dose tapering, as recommended by prescribing guidelines, should be promoted to prevent mental health crisis events among older adults on LTOT.

Longitudinal dose patterns among patients newly initiated on long-term opioid therapy in the United States, 2018 to 2019: an observational cohort study and time-series cluster analysis

ABSTRACT

Opioid prescribing varies widely, and prescribed opioid dosages for an individual can fluctuate over time. Patterns in daily opioid dosage among patients prescribed long-term opioid therapy have not been previously examined. This study uses a novel application of time-series cluster analysis to characterize and visualize daily opioid dosage trajectories and associated demographic characteristics of patients newly initiated on long-term opioid therapy. We used 2018 to 2019 data from the IQVIA Longitudinal Prescription (LRx) all-payer pharmacy database, which covers 92% of retail pharmacy prescriptions dispensed in the United States. We identified a cohort of 277,967 patients newly initiated on long-term opioid therapy during 2018. Patients were stratified into 4 categories based on their mean daily dosage during a 90-day baseline period (<50, 50-89, 90-149, and ≥150 morphine milligram equivalent [MME]) and followed for a 270-day follow-up period. Time-series cluster analysis identified 2 clusters for each of the 3 baseline dosage categories <150 MME and 3 clusters for the baseline dosage category ≥150 MME. One cluster in each baseline dosage category comprised opioid dosage trajectories with decreases in dosage at the end of the follow-up period (80.7%, 98.7%, 98.7%, and 99.0%, respectively), discontinuation (58.5%, 80.0%, 79.3%, and 81.7%, respectively), and rapid tapering (50.8%, 85.8%, 87.5%, and 92.9%, respectively). These findings indicate multiple clusters of patients newly initiated on long-term opioid therapy who experience discontinuation and rapid tapering and highlight potential areas for clinician training to advance evidence-based guideline-concordant opioid prescribing, including strategies to minimize sudden dosage changes, discontinuation, or rapid tapering, and the importance of shared decision-making.

Cross-sectional study of rapid tapering of opioid prescriptions following medical regulatory intervention in Alberta from 2013 to 2020

OBJECTIVE

To determine if inappropriate tapering/discontinuation of opioids to Alberta patients occurred from mid-2013-2020, as unintended consequences of prescribing guidelines, regulations and policies in response to the North American opioid crisis.

DESIGN

A population-based, repeated cross-sectional time-series study.

SETTING

Alberta, Canada.

PARTICIPANTS

Residents of Alberta, Canada aged 18 and older who received an opioid dispense from a community pharmacy from 2013 to 2020.

MAIN OUTCOME MEASURES

The prevalence of potential rapid tapering was measured at a given date (reference day), enveloped by a data window. Dose changes were measured as oral morphine equivalents (OME) per patient, at multiple time points ('data window' around a reference day). Chronic recipients were identified, and their prescriptions were contrasted 90 days before and after the reference day to measure OME/day changes.

RESULTS

Approximately 9000 dispenses (totalling ~6 million OME) per day were analysed from 2013 to 2020. The total number of opioid recipients was highly cyclic in nature (peaking in winter). The number of chronic opioid recipients remained somewhat stable from ~70K in 2013 to ~86K at the end of 2020. The number of chronic high and very high dose recipients presented a significant decrease after 2017. Approximately 11%-12% of chronic high-dose recipients experienced potential rapid dose tapering at a rate of 50% or more prereference to postreference day at any given point of time. For chronic very high dose recipients, approximately 11.5% experience potential rapid dose tapering at a rate of 50% or more prereference to postreference day at any given point of time. Potential discontinuation remained constant and the interventions did not have a significant impact on the trend.

CONCLUSION

The evidence suggests that changes in prescribing guidelines were not associated with an increase of rapid opioid tapering/discontinuation in Alberta.

State-to-State Variation in Opioid Dispensing Changes Following the Release of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain

Importance

Evidence suggests that opioid prescribing was reduced nationally following the 2016 release of the Guideline for Prescribing Opioids for Chronic Pain by the US Centers for Diseases Control and Prevention (CDC). State-to-state variability in postguideline changes has not been quantified and could point to further avenues for reducing opioid-related harms.

Objective

To estimate state-level changes in opioid dispensing following the 2016 CDC Guideline release and explore state-to-state heterogeneity in those changes.

Design, Setting, and Participants

This cross-sectional study included information on opioid prescriptions for US individuals between 2012 and 2018 from an administrative database. Serial cross-sections of monthly opioid dispensing trajectories in each US state and the District of Columbia were analyzed using segmented regression to characterize preguideline dispensing trajectories and to estimate how those trajectories changed following the 2016 guideline release. Data were analyzed January to March 2023.

Exposure

The March 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

Main Outcomes and Measures

Four measures of opioid dispensing: opioid dispensing rate per 100 000 persons, long-acting opioid dispensing rate per 100 000 persons, high-dose (90 or more morphine milligram equivalents [MME] per day) dispensing rate per 100 000 persons, and average per capita MME. All measures were calculated monthly, from January 2012 through December 2018.

Results

Data from approximately 58 900 retail pharmacies were included in analysis, representing approximately 92% of US retail prescriptions. The overall monthly dispensing rate in the US in early 2012 was approximately 7000 per 100 000 population. Following the 2016 guideline release, the already-decreasing slope accelerated nationally for the overall dispensing rate (preguideline slope, -23.19; postguideline slope, -48.97; change in slope, 25.97 [95% CI, 18.67-32.95]), long-acting dispensing rate (preguideline slope, -1.03; postguideline slope, -5.94; change in slope, 4.90 [95% CI, 4.26-5.55]), high-dose dispensing (preguideline slope, -3.52; postguideline slope, -7.63; change in slope, 4.11 [95% CI, 3.49-4.73]), and per-capita MME (preguideline slope, -0.22; postguideline slope, -0.58; change in slope, 0.36 [95% CI, 0.30-0.42]). For all outcomes, nearly all states showed analogous acceleration of an already-decreasing slope, but there was substantial state-to-state heterogeneity. Slope changes (preguideline - postguideline slope) ranged from 9.15 (Massachusetts) to 74.75 (Mississippi) for overall dispensing, 1.88 (Rhode Island) to 13.41 (Maine) for long-acting dispensing, 0.71 (District of Columbia) to 13.68 (Maine) for high-dose dispensing, and 0.06 (Hawaii) to 0.91 (Arkansas) for per capita MME.

Conclusions and Relevance

The 2016 CDC Guideline release was associated with broad reductions in prescription opioid dispensing, and those changes showed substantial geographic variability. Determining the factors associated with these state-level differences may inform further improvements to ensure safe prescribing practices.

Improving Access to Care for Patients Taking Opioids for Chronic Pain: Recommendations from a Modified Delphi Panel in Michigan

Purpose

About 5-8 million US patients take long-term opioid therapy for chronic pain. In the context of policies and guidelines instituted to reduce inappropriate opioid prescribing, abrupt discontinuations in opioid prescriptions have increased and many primary care clinics will not prescribe opioids for new patients, reducing access to care. This may result in uncontrolled pain and other negative outcomes, such as transition to illicit opioids. The objective of this study was to generate policy, intervention, and research recommendations to improve access to care for these patients.

Participants and Methods

We conducted a RAND/UCLA Modified Delphi, consisting of workshops, background videos and reading materials, and moderated web-based panel discussions held September 2020-January 2021. The panel consisted of 24 individuals from across Michigan, identified via expert nomination and snowball recruitment, including clinical providers, health science researchers, state-level policymakers and regulators, care coordination experts, patient advocates, payor representatives, and community and public health experts. The panel proposed intervention, policy, and research recommendations, scored the feasibility, impact, and importance of each on a 9-point scale, and ranked all recommendations by implementation priority.

Results

The panel produced 11 final recommendations across three themes: reimbursement reform, provider education, and reducing racial inequities in care. The 3 reimbursement-focused recommendations were highest ranked (theme average = 4.2/11), including the two top-ranked recommendations: increasing reimbursement for time needed to treat complex chronic pain (ranked #1/11) and bundling payment for multimodal pain care (#2/11). Four provider education recommendations ranked slightly lower (theme average = 6.2/11) and included clarifying the spectrum of opioid dependence and training providers on multimodal treatments. Four recommendations addressed racial inequities (theme average = 7.2/11), such as standardizing pain management protocols to reduce treatment disparities.

Conclusion

Panelists indicated reimbursement should incentivize traditionally lower-paying evidence-based pain care, but multiple strategies may be needed to meaningfully expand access.

Change in opioid and buprenorphine prescribers and prescriptions by specialty, 2016-2021

BACKGROUND

Safer opioid analgesic prescribing and increasing use of medications for opioid use disorder, including buprenorphine, are strategies prioritized to reduce opioid overdose deaths in the United States. Specialty-specific trends in the number of prescribers and prescriptions for opioid analgesics and buprenorphine are not well characterized.

METHODS

We used data from the IQVIA Longitudinal Prescription database for January 1, 2016 through December 31, 2021. We identified opioid and buprenorphine prescriptions based on NDC codes. We classified prescribers into one of 14 mutually exclusive specialty groups. We calculated the number of prescribers and number of prescriptions for opioids and buprenorphine by specialty and year.

RESULTS

From 2016 to 2021, the total number of opioid analgesic prescriptions dispensed decreased by 32% to 121,693,308 and the number of unique opioid analgesic prescribers decreased 7% to 966,369. Over the same time period, the number of buprenorphine prescriptions dispensed increased 36% to 13,909,724 and unique number of buprenorphine prescribers increased 86% to 59,090. Across most specialties we identified a contraction in the number of opioid prescriptions dispensed and opioid prescribers and an expansion in the number of buprenorphine prescriptions dispensed. Among high-volume opioid prescribing specialties, the largest decrease in opioid prescribers was 32% among Pain Medicine clinicians. By 2021, Advanced Practice Practitioners overtook Primary Care clinicians as the highest volume buprenorphine prescribers.

CONCLUSIONS

More work is needed to understand the impact of clinicians who stop prescribing opioids. While the trend in buprenorphine prescribing is encouraging, further expansion is warranted to meet the underlying need.

Predisposing, enabling and reinforcing factors associated with opioid addiction helping behaviour in tri-state Appalachian counties: application of the PRECEDE-PROCEED model-cross-sectional analysis

OBJECTIVES

The overdose epidemic was designated a 'Public Health Emergency' in the USA on 26 October 2017, bringing attention to the severity of this public health problem. The Appalachian region remains substantially impacted by the effects from years of overprescription of opioids, and subsequently opioid non-medical use and addiction. This study aims to examine the utility of the PRECEDE-PROCEED model constructs (ie, predisposing, reinforcing and enabling factors) to explain opioid addiction helping behaviour (ie, helping someone who has an opioid addiction) among members of the public living in tri-state Appalachian counties.

DESIGN

Cross-sectional study.

SETTING

Rural county in the Appalachian region of the USA.

PARTICIPANTS

A total of 213 participants from a retail mall in a rural Appalachian Kentucky county completed the survey. Most participants were between the ages of 18 and 30 years (n=68; 31.9%) and identified as men (n=139; 65.3%).

PRIMARY OUTCOME MEASURE

Opioid addiction helping behaviour.

RESULTS

The regression model was significant (F _{(6, 180)}=26.191, p<0.001) and explained 44.8% of the variance in opioid addiction helping behaviour (R²=0.448). Attitude towards helping someone with opioid addiction (B=0.335; p<0.001), behavioural skills (B=0.208; p=0.003), reinforcing factors (B=0.190; p=0.015) and enabling factors (B=0.195; p=0.009) were all significantly associated with opioid addiction helping behaviour.

CONCLUSIONS

PRECEDE-PROCEED model constructs have utility to explain opioid addiction helping behaviour among individuals in a region greatly impacted by the overdose epidemic. This study provides an empirically tested framework for future programmes addressing helping behaviour related to opioid non-medical use.

Chronic low back pain comorbidity count and its impact on exacerbating opioid and non-opioid prescribing behavior

RESEARCH OBJECTIVES

The objective of the study was to determine the characteristics of chronic low back pain (CLBP) comorbidity and its impact on opioid and non-opioid treatments among Chicagoland patients with CLBP.

DESIGN

A retrospective cross-sectional study comparing differences in comorbidity and treatment patterns among Chicagoland patients with CLBP against a matched control arm without chronic low back pain (NCLBP).

SETTING

Academic hospital system outpatient services.

PARTICIPANTS

Using the International Classification of Diseases, 10th Revision codes (ICD 10) 9589 patients were identified with CLBP with a median age of 57 years old and 62.32% female distribution. The NCLBP group comprised 9589 age-, sex-, race-, and region-matched patients.

RESULTS

An increased prevalence across all 17 studied comorbidities was found in CLBP patients as compared to NCLBP patients. CLBP patients carried an average of 3.5 comorbidities compared with 2.4 comorbidities in NCLBP patients. Rheumatoid arthritis (RA), joint arthritis, and obesity had the strongest relationship with CLBP. Additionally, we found that the most prescribed treatment for CLBP were opioids, which ranked above NSAIDs and physical therapy. 56% of CLBP patients were prescribed opioids as compared to 36% of NCLBP patients (Odds Ratio = 2.28, 95% CI: 2.16-2.42). Tramadol was the agent with the strongest relationship to CLBP. CLBP patients were more likely to use two or more opioids concomitantly. The number of total treatments was positively associated with the number of comorbidities in both CLBP and NCLBP patients (Cochran-Armitage trend test p < 0.0001).

CONCLUSIONS

Chronic low back pain patients showed a higher number of comorbidities than their NCLBP counterparts. Comorbidity count trended positively with higher treatment burden with opioids being the most prescribed treatment, often with poly-opioid use, over conservative modalities such as NSAIDs and physical therapy.

Chronic and Sustained High-Dose Opioid Use in an Integrated Health System

INTRODUCTION

The Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain released in 2016 had led to decreases in opioid prescribing. This study sought to examine chronic and sustained high-dose prescription opioid use in an integrated health system.

METHODS

A serial cross-sectional study was conducted in 2021 to estimate the annual age-adjusted prevalence and incidence of chronic and high-dose opioid use among demographically diverse noncancer adults in an integrated health system in Southern California during 2013-2020. Interrupted time-series analysis with segmented regression was conducted to estimate changes in the trends in annual rates before (2013-2015) and after (2017-2020) the 2016 guideline, treating 2016 as a wash-out period.

RESULTS

Prevalence and incidence of chronic use and sustained high-dose use had started to decrease after a health system intervention program before the 2016 Centers for Disease Control and Prevention guideline release and continued to decline after the guideline. Among those with sustained high-dose use, there was a substantial decrease in persons with an average daily dosage ≥90 morphine milligram equivalent and concurrent benzodiazepine use. An accelerated decrease in prevalent chronic use after the guideline was observed (slope change: -11.1 [95% CI= -20.3, -1.9] users/10,000 person-years, p=0.03). The incidence of chronic use and sustained high-dose use continued to decrease after the guideline release but at a slower pace.

CONCLUSIONS

Implementing evidence-based prescribing guidelines was associated with a decrease in chronic and sustained high-dose prescription opioid use.

Population-Based Opioid Prescribing and Overdose Deaths in the USA: an Observational Study

BACKGROUND

Rising opioid-related death rates have prompted reductions of opioid prescribing, yet limited data exist on population-level associations between opioid prescribing and opioid-related deaths.

OBJECTIVE

To evaluate population-level associations between five opioid prescribing measures and opioid-related deaths.

DESIGN

An ecological panel analysis was performed using linear regression models with year and commuting zone fixed effects.

PARTICIPANTS

People ≥10 years aggregated into 886 commuting zones, which are geographic regions collectively comprising the entire USA.

MAIN MEASURES

Annual opioid prescriptions were measured with IQVIA Real World Longitudinal Prescription Data including 76.5% (2009) to 90.0% (2017) of US prescriptions. Prescription measures included opioid prescriptions per capita, percent of population with ≥1 opioid prescription, percent with high-dose prescription, percent with long-term prescription, and percent with opioid prescriptions from ≥3 prescribers. Outcomes were age- and sex-standardized associations of change in opioid prescriptions with change in deaths involving any opioids, synthetics other than methadone, heroin but not synthetics or methadone, and prescription opioids, but not other opioids.

KEY RESULTS

Change in total regional opioid-related deaths was positively correlated with change in regional opioid prescriptions per capita (β=.110, p<.001), percent with ≥1 opioid prescription (β=.100, p=.001), and percent with high-dose prescription (β=.081, p<.001). Change in total regional deaths involving prescription opioids was positively correlated with change in all five opioid prescribing measures. Conversely, change in total regional deaths involving synthetic opioids was negatively correlated with change in percent with long-term opioid prescriptions and percent with ≥3 prescribers, but not for persons ≥45 years. Change in total regional deaths in heroin was not associated with change in any prescription measure.

CONCLUSIONS

Regional decreases in opioid prescriptions were associated with declines in overdose deaths involving prescription opioids, but were also associated with increases in deaths involving synthetic opioids (primarily fentanyl). Individual-level inferences are limited by the ecological nature of the analysis.

Association Between Opioid Tapering and Subsequent Health Care Use, Medication Adherence, and Chronic Condition Control

Importance

Opioid tapering has been associated with negative consequences, such as increased overdoses and mental health needs. Tapering could also alter use of health care services and worsen care of comorbid conditions through disruption in primary care.

Objective

To evaluate tapering of stable long-term opioid therapy (LTOT) and subsequent health care service use and chronic condition care.

Design, Setting, and Participants

A retrospective cohort study was conducted from January 1, 2008, to December 31, 2019. Data analysis was performed from July 9, 2020, to December 9, 2022. Data from the Optum Labs Data Warehouse, which contains deidentified retrospective administrative claims data and linked electronic health record data for commercial and Medicare Advantage enrollees, were used. Adults aged 18 years or older prescribed stable doses of LTOT at 50 morphine milligram equivalents or more per day during a 12-month baseline period were included, including subcohorts with hypertension or diabetes.

Exposures

Opioid tapering, with 15% or more relative reduction in mean daily dose in 6 overlapping periods during 6 months.

Main Outcomes and Measures

Emergency department visits, hospitalizations, primary care and specialist visits, antihypertensive or antiglycemic medication adherence, and blood pressure and hemoglobin A1c levels during up to 12 months' follow-up. Covariates included sociodemographic characteristics, comorbidities, health care use, and chronic condition control.

Results

Among 113 604 patients (60 764 [53.5%] women; mean [SD] age, 58.1 [11.8] years) prescribed LTOT, 41 207 had hypertension and 23 335 had diabetes; in all cohorts, approximately half were women, and half were aged 50 to 65 years. In the overall cohort, tapering was associated with more emergency department visits (adjusted incidence rate ratio [aIRR], 1.19; 95% CI, 1.16-1.21) and hospitalizations (aIRR, 1.16; 95% CI, 1.12-1.20), with similar magnitude associations in the hypertension and diabetes subcohorts. Tapering was associated with fewer primary care visits in the overall cohort (aIRR, 0.95; 95% CI, 0.94-0.96) and hypertension subcohort (aIRR, 0.98; 95% CI, 0.97-0.99). For the hypertension or diabetes subcohorts, tapering was associated with reduced medication adherence (hypertension: aIRR, 0.60; 95% CI, 0.59-0.62; diabetes: aIRR, 0.69; 95% CI, 0.67-0.71) and small increases in diastolic blood pressure and hemoglobin A1c level.

Conclusions and Relevance

In this cohort study of patients prescribed LTOT, opioid tapering was associated with more emergency department visits and hospitalizations, fewer primary care visits, and reduced antihypertensive and antidiabetic medication adherence. These outcomes may represent unintended negative consequences of opioid tapering for policy makers and clinicians to consider.

Opioid withdrawal symptoms after neurolytic splanchnic nerve block in cancer patients

PURPOSE

Few reports on opioid withdrawal (OW) due to opioid tapering in cancer patients have been published. The incidence of and risk factors for OW after neurolytic splanchnic nerve block (NSNB) are unknown. This study aimed to elucidate the incidence of and risk factors for OW among cancer patients who could have reduced opioid doses after NSNB.

METHODS

This was a multicenter, retrospective, observational study. We reviewed the medical charts of patients who underwent NSNB for intractable cancer pain at four tertiary hospitals in Yokohama City from April 2005 to October 2020. We included patients whose opioid dose was reduced by > 5 mg/day (equivalent oral morphine dose) within 14 days after NSNB. We classified the patients into two groups according to the presence or absence of OW symptoms and compared them.

RESULTS

Of the 50 patients who underwent NSNB, 24 were included in the study. OW was observed in five (20.8%) patients. Pain and opioid use duration were significantly longer in OW patients than in non-OW patients (median pain duration 689 vs. 195 days; P < 0.043 and median opioid use duration 486 vs. 136 days; P < 0.030). The opioid tapering dose was significantly larger in patients with OW than in those without OW (median opioid tapering dose 75 vs. 40 mg; P < 0.046).

CONCLUSIONS

OW was observed in 20.8% of the patients in the study. A longer pain and opioid use duration and a larger opioid tapering dose may predispose patients to OW.

Recent tapering from long-term opioid therapy and odds of opioid-related hospital use

PURPOSE

The number of patients tapered from long-term opioid therapy (LTOT) has increased in recent years in the United States. Some patients tapered from LTOT report improved quality of life, while others face increased risks of opioid-related hospital use. Research has not yet established how the risk of opioid-related hospital use changes across LTOT dose and subsequent tapering. Our objective was to examine associations between recent tapering from LTOT with odds of opioid-related hospital use.

METHODS

Case-crossover design using 2014-2018 health information exchange data from Indiana. We defined opioid-related hospital use as hospitalizations, and emergency department (ED) visits for a drug overdose, opioid abuse, and dependence. We defined tapering as a 15% or greater dose reduction following at least 3 months of continuous opioid therapy of 50 morphine milligram equivalents (MME)/day or more. We used conditional logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Recent tapering from LTOT was associated with increased odds of opioid-related hospital use (OR: 1.50, 95%CI: 1.34-1.63), ED visit (OR: 1.52; 95%CI: 1.35-1.72), and inpatient hospitalization (OR: 1.40; 95%CI: 1.20-1.65). We found no evidence of heterogeneity of the effect of tapering on opioid-related hospital use by gender, age, and race. Recent tapering among patients on a high baseline dose (>300 MME) was associated with increased odds of opioid-related hospital use (OR: 2.95, 95% CI: 2.12-4.11, p < 0.001) compared to patients on a lower baseline doses.

CONCLUSIONS

Recent tapering from LTOT is associated with increased odds of opioid-related hospital use.

Development and Testing of a Communication Intervention to Improve Chronic Pain Management in Primary Care: A Pilot Randomized Clinical Trial

OBJECTIVES

Effective communication skills are essential for optimally managing chronic pain and opioids. This exploratory, sequential mixed methods study tested the effect of a novel framework designed to improve pain-related communication and outcomes.

METHODS

Study 1 developed a novel 5-step framework for helping primary care clinicians discuss chronic pain and opioids with patients. Study 2 pilot tested an intervention for teaching this framework using standardized patient instructors-actors trained to portray patients and provide immediate clinician feedback-deployed during regular clinic hours. Primary care physicians were randomized to receive either the intervention or pain management recommendations from the Centers for Disease Control and Prevention. Primary outcomes were pain-related interference at 2 months and clinician use of targeted communication skills (coded from transcripts of audio-recorded visits); secondary outcomes were pain intensity at 2 months, clinician self-efficacy for communicating about chronic pain, patient experience, and clinician-reported visit difficulty.

RESULTS

We enrolled 47 primary care physicians from 2 academic teaching clinics and recorded visits with 48 patients taking opioids for chronic pain who had an appointment scheduled with an enrolled physician. The intervention was not associated with significant changes in primary or secondary outcomes other than clinician self-efficacy, which was significantly greater in the intervention group.

DISCUSSION

This study developed a novel framework and intervention for teaching clinician pain-related communications skills. Although the intervention showed promise, more intensive or multicomponent interventions may be needed to have a significant impact on clinicians' pain-related communication and pain outcomes.

Comparative Effectiveness of Opioid Tapering or Abrupt Discontinuation vs No Dosage Change for Opioid Overdose or Suicide for Patients Receiving Stable Long-term Opioid Therapy

IMPORTANCE

Opioid dosage tapering has emerged as a strategy to reduce harms associated with long-term opioid therapy; however, evidence supporting this approach is limited.

OBJECTIVE

To identify the association of opioid tapering or abrupt discontinuation with opioid overdose and suicide events among patients receiving stable long-term opioid therapy without evidence of opioid misuse.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness study with a trial emulation approach used a large US claims data set of individuals with commercial insurance or Medicare Advantage who were aged 18 years or older and receiving stable long-term opioid therapy without evidence of opioid misuse between January 1, 2010, and December 31, 2018. Statistical analysis was performed from January 17, 2020, through November 12, 2021.

INTERVENTIONS

Three opioid dosage strategies: stable dosage, tapering (dosage reduction ≥15%), or abrupt discontinuation.

MAIN OUTCOMES AND MEASURES

Time to opioid overdose or suicide event identified from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes in medical claims over 11 months of follow-up. Inverse probability weighting was used to adjust for baseline confounders. The primary analysis used an intention-to-treat approach; follow-up after assignment regardless of changes in opioid dose was included. A per-protocol analysis was also conducted, in which episodes were censored for lack of adherence to assigned treatment.

RESULTS

A cohort of 199 836 individuals (45.1% men; mean [SD] age, 56.9 [12.4] years; and 57.6% aged 45-64 years) had 415 123 qualifying, long-term opioid therapy episodes; 87.1% of episodes were considered stable, 11.1% were considered a taper, and 1.8% were considered abrupt discontinuation. The adjusted cumulative incidence of opioid overdose or suicide events 11 months after baseline was 0.96% (95% CI, 0.92%-0.99%) with a stable dosage strategy, 1.10% (95% CI, 0.99%-1.22%) with a tapered dosage strategy, and 1.28% (95% CI, 0.93%-1.38%) with an abrupt discontinuation strategy. The risk difference between a taper and a stable dosage was 0.15% (95% CI, 0.03%-0.26%), and the risk difference between abrupt discontinuation and a stable dosage was 0.33% (95% CI, -0.03% to 0.74%). Results were similar using the per-protocol approach.

CONCLUSIONS AND RELEVANCE

This study identified a small absolute increase in risk of harms associated with opioid tapering compared with a stable opioid dosage. 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.

Development and implementation of a prescription opioid registry across diverse health systems

Objective

Develop and implement a prescription opioid registry in 10 diverse health systems across the US and describe trends in prescribed opioids between 2012 and 2018.

Materials and Methods

Using electronic health record and claims data, we identified patients who had an outpatient fill for any prescription opioid, and/or an opioid use disorder diagnosis, between January 1, 2012 and December 31, 2018. The registry contains distributed files of prescription opioids, benzodiazepines and other select medications, opioid antagonists, clinical diagnoses, procedures, health services utilization, and health plan membership. Rates of outpatient opioid fills over the study period, standardized to health system demographic distributions, are described by age, gender, and race/ethnicity among members without cancer.

Results

The registry includes 6 249 710 patients and over 40 million outpatient opioid fills. For the combined registry population, opioid fills declined from a high of 0.718 per member-year in 2013 to 0.478 in 2018, and morphine milligram equivalents (MMEs) per fill declined from 985 MMEs per fill in 2012 to 758 MMEs in 2018. MMEs per member declined from 692 MMEs per member in 2012 to 362 MMEs per member in 2018.

Conclusion

This study established a population-based opioid registry across 10 diverse health systems that can be used to address questions related to opioid use. Initial analyses showed large reductions in overall opioid use per member among the combined health systems. The registry will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use.

Association Between Exposure to Complementary and Integrative Therapies and Opioid Analgesic Daily Dose Among Patients on Long-term Opioid Therapy

OBJECTIVES

To describe the association between exposure to selected complementary and integrative health (CIH) modalities and the trajectory of prescribed opioid analgesic dose within a national cohort of patients receiving long-term opioid therapy (LTOT) in the Veterans Health Administration (VHA).

MATERIALS AND METHODS

Using national data from VHA electronic health records between October 1, 2017 and September 30, 2019, CIH use was analyzed among 57,437 patients receiving LTOT within 18 VHA facilities serving as evaluation sites of VHA's Whole Health System of Care. Using linear mixed effects modeling controlling for covariates, opioid dose was modeled as a function of time, CIH exposure, and their interaction.

RESULTS

Overall, 11.91% of patients on LTOT used any of the focus CIH therapies; 43.25% of those had 4 or more encounters. Patients used acupuncture, chiropractic care, and meditation modalities primarily. CIH use was associated with being female, Black, having a mental health diagnosis, obesity, pain intensity, and baseline morphine-equivalent daily dose. Mean baseline morphine-equivalent daily dose was 40.81 milligrams and dose decreased on average over time. Controlling for covariates, patients with any CIH exposure experienced 38% faster dose tapering, corresponding to a mean difference in 12-month reduction over patients not engaging in CIH of 2.88 milligrams or 7.06% of the mean starting dose.

DISCUSSION

Results support the role of CIH modalities in opioid tapering. The study design precludes inference about the causal effects of CIH on tapering. Analyses did not consider the trend in opioid dose before cohort entry nor the use of other nonopioid treatments for pain. Future research should address these questions and consider tapering-associated adverse events.

Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering

Importance

Patients prescribed long-term opioid therapy are increasingly undergoing dose tapering. Recent studies suggest that tapering is associated with short-term risks of substance misuse, overdose, and mental health crisis, although lower opioid dose could reduce risks of adverse events over the longer term.

Objective

To assess the longer-term risks of overdose or mental health crisis associated with opioid dose tapering.

Design, Setting, and Participants

This is a cohort study using an exposure-crossover analysis. Data were obtained from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims and enrollment records for commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities, and geographical regions across the US. Participants were US adults who underwent opioid dose tapering from 2008 to 2017 after a 12-month baseline period of stable daily dosing of 50 morphine milligram equivalents or higher and who had at least 1 month of long-term follow-up during a postinduction period beginning 12 months after taper initiation. Data analysis was performed from October 2021 to April 2022.

Exposures

Opioid tapering, defined as 15% or more relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period after the stable baseline period.

Main Outcomes and Measures

Emergency or hospital encounters for drug overdose or withdrawal and mental health crisis (depression, anxiety, or suicide attempt). Outcome counts were assessed in pretaper and postinduction periods (from 12 to 24 months after taper initiation).

Results

The study included 21 515 tapering events among 19 377 patients with a mean (SD) of 9.1 (2.7) months of postinduction follow-up per event (median [IQR], 10 [8-11] months). Patients had a mean (SD) age of 56.9 (11.2) years, 11 581 (53.8%) were female, and 8217 (38.2%) had commercial insurance (vs Medicare Advantage). In conditional negative binomial regression analyses, adjusted incidence rate ratios for the postinduction period compared with the pretaper period were 1.57 (95% CI, 1.42-1.74) for overdose or withdrawal and 1.52 (95% CI, 1.35-1.71) for mental health crisis.

Conclusions and Relevance

These findings suggest that opioid tapering was associated with increased rates of overdose, withdrawal, and mental health crisis extending up to 2 years after taper initiation.

Sex, gender, and the opioid epidemic: Crucial implications for acute care

Introduction

The opioid epidemic continues to escalate in the United States, exacerbated significantly by the COVID-19 pandemic. Necessary steps in acute care medicine to expand efforts to combat this epidemic involve increased emergency department engagement of patients with opioid use disorder (OUD) and an incorporation of evolving sex- and gender-based factors that affect this disease presentation and management course.

Methods & Aims

An ever-increasing amount of peer-reviewed, evidence-based literature has shed light on the important biologic and sociocultural variables, specifically sex and gender, which impact OUD trajectory and outcomes. As a collaborative effort of the Sex and Gender in Emergency Medicine (SGEM) Interest Group, a community within the Society for Academic Emergency Medicine (SAEM), we sought to consider, review, and summarize clinically pertinent information as a comprehensive introduction to this topic for the emergency medicine (EM) clinician and educator.

Results

A selected overview of current evidence-based data and publications, to include current epidemiologic trends, opioid-based physiology and pathophysiology, as well as opioid use disorder management and outcomes, through a sex- and gender-based lens, was reviewed and included in this summary. Also discussed are implications and recommendations for EM educators seeking insight and resources for continuing, graduate, and/or undergraduate education on this topic.

Conclusion

Incorporation of emerging sex- and gender-specific scientific knowledge into clinical context represents a critical link to effective management of the OUD patient in the ED. Similarly, integration of this information into EM education represents an essential step for both sex- and gender-based medicine and opioid-specific training.

Patterns in Nonopioid Pain Medication Prescribing After the Release of the 2016 Guideline for Prescribing Opioids for Chronic Pain

IMPORTANCE

In 2016, the Centers for Disease Control and Prevention (CDC) released the evidence-based Guideline for Prescribing Opioids for Chronic Pain. How the release of this guideline coincided with changes in nonopioid pain medication prescribing rates remains unknown.

OBJECTIVE

To evaluate changes in nonopioid pain medication prescribing after the 2016 CDC guideline release and to assess the heterogeneity in these changes as a function of patient demographic and clinical characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study constructed 7 (4 preguideline and 3 postguideline) annual cohorts using claims data from the national Optum Clinformatics Data Mart Database for the period January 1, 2011, through December 31, 2018. The cohorts included adults with commercial insurance, no cancer or palliative care claims, and 2 years of continuous insurance enrollment. Individuals could qualify for inclusion in multiple cohorts. Each cohort covered a 2-year period, with year 1 as the baseline period used to calculate opioid exposure and other clinical characteristics and year 2 as the follow-up period used to calculate prescribing outcomes. Data were analyzed in March 2022.

EXPOSURES

The CDC guideline, which was released in March 2016.

MAIN OUTCOMES AND MEASURES

The primary outcome was receipt of any nonopioid pain medication prescriptions (analgesics or antipyretics, anticonvulsants, antidepressants, and nonsteroidal anti-inflammatory drugs) during the follow-up period. This postguideline prescribing pattern was compared with estimates based on the preguideline prescribing pattern, and then the differences were stratified by patient clinical characteristics (chronic pain, recent opioid exposure, substance use disorder, anxiety disorder, and mood disorder).

RESULTS

A total of 15 879 241 individuals (2015 mean [SD] age, 50.2 [18.6] years; 8 298 271 female patients [52.3%]) qualified for inclusion in 1 or more cohorts. Logistic regression models showed that nonopioid pain medication prescribing odds were higher by 3.0% (95% CI, 2.6%-3.3%) in postguideline year 1, by 8.7% (95% CI, 8.3%-9.2%) in postguideline year 2, and by 9.7% (95% CI, 9.2%-10.3%) in postguideline year 3 than the preguideline pattern-based estimates. The magnitude of the postguideline departures from the preguideline pattern varied by several clinical characteristics (chronic pain, recent opioid exposure, anxiety disorder, and mood disorder). The largest departure was found among those with chronic pain, with postguideline prescribing being higher than estimated in postguideline year 2 (13.6%; 95% CI, 12.7%-14.6%) and postguideline year 3 (14.9%; 95% CI, 13.8%-16.0%).

CONCLUSIONS AND RELEVANCE

Results of this study showed increases in nonopioid pain medication prescribing after the release of the 2016 CDC guideline, suggesting that the guideline may be associated with an increase in guideline-concordant care, but additional studies are needed to understand the role of other secular changes in the opioid policy landscape and other sources of nonopioid medication use.

Toward Safer Opioid Prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial

BACKGROUND

The 2016 U.S. Centers for Disease Control Opioid Prescribing Guideline (CDC Guideline) is currently being revised amid concern that it may be harmful to people with chronic pain on long-term opioid therapy (CP-LTOT). However, a methodology to faithfully implement the CDC guideline, measure prescriber adherence, and systematically test its effect on patient and public health outcomes is lacking. We developed and tested a CDC Guideline implementation strategy (termed TOWER), focusing on an outpatient HIV-focused primary care setting.

METHODS

TOWER was developed in a stakeholder-engaged, multi-step iterative process within an Information, Motivation and Behavioral Skills (IMB) framework of behavior change. TOWER consists of: 1) a patient-facing opioid management app (OM-App); 2) a progress note template (OM-Note) to guide the office visit; and 3) a primary care provider (PCP) training. TOWER was evaluated in a 9-month, randomized-controlled trial of HIV-PCPs (N = 11) and their patients with HIV and CP-LTOT (N = 40). The primary outcome was CDC Guideline adherence based on electronic health record (EHR) documentation and measured by the validated Safer Opioid Prescribing Evaluation Tool (SOPET). Qualitative data including one-on-one PCP interviews were collected. We also piloted patient-reported outcome measures (PROMs) reflective of domains identified as important by stakeholders (pain intensity and function; mood; substance use; medication use and adherence; relationship with provider; stigma and discrimination).

RESULTS

PCPs randomized to TOWER were 48% more CDC Guideline adherent (p < 0.0001) with significant improvements in use of: non-pharmacologic treatments, functional treatment goals, opioid agreements, prescription drug monitoring programs (PDMPs), opioid benefit/harm assessment, and naloxone prescribing. Qualitative data demonstrated high levels of confidence in conducting these care processes among intervention providers, and that OM-Note supported these efforts while experience with OM-App was mixed. There were no intervention-associated safety concerns (defined as worsening of any of the PROMs).

CONCLUSIONS

CDC-guideline adherence can be promoted and measured, and is not associated with worsening of outcomes for people with HIV receiving LTOT for CP. Future work would be needed to document scalability of these results and to determine whether CDC-guideline adherence results in a positive effect on public health. Trial registration https://clinicaltrials.gov/ct2/show/NCT03669939 . Registration date: 9/13/2018.

Dose tapering, increases, and discontinuity among patients on long-term high-dose opioid therapy in the United States, 2017-2019

BACKGROUND

While reduced exposure to prescription opioids may decrease risks, including overdose and opioid use disorder, abrupt tapering or discontinuation may pose new risks.

OBJECTIVES

To examine potentially unsafe tapering and discontinuation among dosage changes in opioid prescriptions dispensed to US patients on high-dose long-term opioid therapy.

DESIGN

Longitudinal observational study of adults (≥18 years) on stable high-dose (≥50 oral morphine milligram equivalents [MME] daily dosage) long-term opioid therapy during a 180-day baseline and a 360-day follow-up using all-payer pharmaceutical claims data, 2017-2019.

MEASURES

Dosage tapering, increases, and/or stability during follow-up; sustained dosage stability, reductions, or discontinuation at the end of follow-up; and tapering rate. Patients could experience more than one outcome during follow-up.

RESULTS

Among 595,078 patients receiving high-dose long-term opioid therapy in the sample, 26.7% experienced sustained dosage reductions and 9.3% experienced discontinuation. Among patients experiencing tapering, 62.0% experienced maximum taper rates between > 10-40% reductions per month and 36.1% experienced monthly rates ≥ 40%. Among patients with mean baseline daily dosages ≥ 150 MME, 47.7% experienced a maximum taper rate ≥ 40% per month. Relative to baseline, 19.7% of patients experiencing tapering had long-term dosage reductions ≥ 40% per month at the end of follow-up.

IMPLICATIONS

Dosage changes for patients on high-dose long-term opioid therapy may warrant special attention, particularly over shorter intervals, to understand how potentially sudden tapering and discontinuation can be reduced while emphasizing patient safety and shared decision-making. Rapid discontinuation of opioids can increase risk of adverse outcomes including opioid withdrawal.

Rapid Discontinuation of Chronic, High-Dose Opioid Treatment for Pain: Prevalence and Associated Factors

PURPOSE

To examine the prevalence of rapid discontinuation of chronic, high-dose opioid analgesic treatment, and identify associated patient, clinician, and community factors.

METHODS

Using 2017-2018 retail pharmacy claims data from IQVIA, we identified chronic, high-dose opioid analgesic treatment episodes discontinued during these years and determined the percent of episodes meeting criteria for rapid discontinuation. We used multivariable logistic regression to estimate the probability of rapid discontinuation, conditional on having a discontinued chronic, high-dose opioid treatment episode, as a function of patient, provider, and county characteristics.

RESULTS

We identified 810,120 new, chronic, high-dose opioid treatment episodes discontinued in 2017 or 2018, of which 72.0% (n=583,415) were rapidly discontinued. Rapid discontinuation was significantly more likely among Medicare (aOR 1.14, 95% CI 1.12 to 1.15) and Medicaid enrollees (aOR 1.03, 95% CI 1.02 to 1.05) compared to the commercially insured; in counties with higher fatal overdose rates (aOR 1.03, 95% CI 1.01 to 1.04) compared to counties with the lowest fatal overdose rates; and in counties with a higher percentage of non-white residents (aOR 1.21 for counties in the highest quartile relative to the lowest, 95% CI 1.19 to 1.24). Likelihood of rapid discontinuation also varied by prescriber specialty.

CONCLUSIONS

Most chronic, high-dose opioid treatment episodes that ended in 2017 or 2018 were discontinued more rapidly than recommended by clinical guidelines, raising concerns about adverse patient outcomes. Our findings highlight the need to understand what drives discontinuation and to inform safer opioid tapering and discontinuation practices.

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

OBJECTIVE

To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.

DESIGN

Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Original research in English. Case reports and cross sectional studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).

RESULTS

Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05).

CONCLUSIONS

Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.

REVIEW REGISTRATION

PROSPERO CRD42020140943.

Abrupt Discontinuation From Long-Term Opioid Therapy in Massachusetts, 2015-2018

INTRODUCTION

In response to the opioid overdose crisis, providers were urged to taper and discontinue patients from long-term opioid therapy; however, abrupt discontinuation may lead to poor health outcomes. This study aims to determine abrupt and tapered discontinuation rates and identify the patient and provider characteristics associated with abrupt discontinuation.

METHODS

Data were from the Massachusetts Prescription Monitoring Program, 2015-2018. Patients discontinued from long-term opioid therapy were included in the analysis. Differences between abrupt and tapered discontinuations were identified with bivariate correlations, and variables independently associated with abrupt discontinuation were identified using multivariable Poisson regression analyses. Data were analyzed during 2019-2021.

RESULTS

In total, 277,485 patients experienced 359,320 discontinuations, of which 33.7% (n=120,964) were abrupt. Of all discontinuations, 55.7% were among female patients, and 57.9% were among patients aged >55 years. The ratio of abrupt to tapered discontinuations increased from 1:2.11 in 2015 to 1:1.75 in 2018. In bivariate analysis, prescribers with more patients receiving monthly opioid prescriptions were less likely to abruptly discontinue patients (29.0, IQR=13.9, 55.3 vs 18.8, IQR=5.84, 43.9, p<0.001), as were prescribers who wrote more monthly opioid prescriptions (36.0, IQR=16.8, 70.8 vs 25.4, IQR=7.40, 58.3, p<0.001). Multivariable results indicated that abrupt discontinuation was independently associated with male sex (RR=1.31, 95% CI=1.29, 1.1.32), younger age (RR=0.872, 95% CI=0.869, 0.874), greater distance between patient and prescriber (RR=1.0075, 95% CI=1.0072, 1.0078), and longer long-term opioid therapy duration (RR=1.021, 95% CI=1.021, 1.0122 for every month increase).

CONCLUSIONS

Among all long-term opioid therapy discontinuations, abrupt discontinuation is increasing. Evidence-based approaches to managing and tapering long-term opioid therapy are urgently needed.

Reduction of Long-Term Opioid Prescribing for Back Pain in Community Health Centers After a Medicaid Policy Change

INTRODUCTION

Beginning around 2011, innumerable policies have aimed to improve pain treatment while minimizing harms from excessive use of opioids. It is not known whether changing insurance coverage for specific conditions is an effective strategy. We describe and assess the effect of an innovative Oregon Medicaid back/neck pain coverage policy on opioid prescribing patterns.

METHODS

This retrospective cohort study uses electronic health record data from a network of community health centers (CHCs) in Oregon to analyze prescription opioid dose changes among patients on long-term opioid treatment (LOT) affected by the policy.

RESULTS

Of the 1,789 patients on LOT at baseline, 41.6% had an average daily dose of <20 morphine milligram equivalents (MME), 32.3% had ≥20 to <50 MME, 14.5% had ≥50 to <90 MME, and 11.6% ≥90 MME. Around half of each group discontinued opioids within the 18-month policy period. Those who discontinued did so gradually (average of 11 months) regardless of starting dosage. Predictors of discontinuation included: diagnosis of opioid use disorder, older, non-Hispanic white, and less medical complexity.

CONCLUSIONS

Regardless of starting opioid dose, nearly half of patients affected by the 2016 Oregon Medicaid back/neck pain treatment policy no longer received opioid prescriptions by the end of the 18-month study period; another 30% decreased their dose. Gradual dose reduction was typical. These outcomes suggest that the policy impacted opioid prescribing. Understanding patient experiences resulting from such policies could help clinicians and policy makers navigate the complex balance between potential harms and benefits of LOT.

Impact of changes in opioid funding and clinical policies on rapid tapering of opioids in Ontario, Canada

ABSTRACT

Reports have emerged of abrupt tapering among recipients of long-term prescription opioids to conform new prescribing guidelines. We conducted a population-based, repeated cross-sectional time-series study among very high-dose (≥200 MME) opioid recipients in Ontario, Canada, to examine changes in the monthly prevalence of rapid tapering from 2014 to 2018, defined as recipients experiencing either a ≥50% reduction in daily doses or abrupt discontinuation sustained for 30 days. Interventional autoregressive integrated moving average models were used to test for significant changes following key guidelines and drug policies and programs. A sensitivity analysis examined rapid tapering sustained for 90 days. The monthly prevalence of rapid tapering events was stable from January 2014 to September 2016 (average monthly prevalence: 1.4%) but increased from 1.4% in October 2016 to 1.8% in April 2017 (P = 0.001), coincident with Ontario's Fentanyl Patch-for-Patch Return Program implementation. Transient spikes in the prevalence of rapid tapering also occurred 2 months after Ontario's delisting of publicly funded high-strength opioids and the release of updated Canadian Opioid Prescribing Guideline for Chronic Pain, reaching 2.3% in March 2017 and July 2017, respectively. However, this prevalence decreased to 1.2% in December 2018 (P < 0.0001). Although the prevalence of abrupt opioid discontinuation was lower, similar trends were observed. Our sensitivity analysis examining long-lasting rapid tapering found similar trends but lower prevalence, with no changes in complete discontinuation. These temporary increases in rapid tapering events highlight the need for improved communication and evidence-based resources for prescribers to minimize negative consequences of evolving policies and guidelines.

Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic

BACKGROUND

After decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing.

OBJECTIVE

To evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013-2014.

DESIGN

Retrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies.

PATIENTS

273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017-2018.

INTERVENTIONS

Policies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases.

MAIN MEASURES

Opioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview.

KEY RESULTS

The interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: -52.0 MME [95% confidence interval: -109.9, -10.6]; year 2: -106.2 MME [-195.0, -34.6]; year 3: -98.6 MME [-198.7, -23.9]; year 4: -72.6 MME [-160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [-0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year.

CONCLUSIONS

Clinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change.

Attitudes Toward a Pre-authorized Concealed Opioid Taper: A Qualitative Analysis of Patient and Clinician Perspectives

Standard opioid tapers tend to be associated with increased patient anxiety and higher pain ratings. Pre-authorized concealed opioid reductions may minimize expectations such as fear of increased pain due to the reduction of opioids and, prolong analgesic benefits in experimental settings. We recently observed that patients and clinicians are open to concealed opioid tapering. However, little is known about the "why" behind their attitudes. Based on this lack of data, we analyzed qualitative responses to survey questions on patients' and clinicians' acceptance of a concealed opioid reduction for chronic pain. Seventy-four patients with a history of high dose opioid therapy and 49 clinicians completed a web-based questionnaire with open-ended questions examining responses to two hypothetical clinical trials comparing a concealed opioid reduction pre-authorized by patients vs. standard tapering. We used content analysis based on qualitative descriptive methodology to analyze comments from the patients and clinicians. Five themes were identified: informed consent; anxiety; safety; support; and ignorance is bliss, or not. These themes highlight the overall positive attitudes toward concealed opioid tapers. Our findings reinforce the importance of patient-centered care and are expected to inform the design of clinical trials from both the patient and clinician perspective. This qualitative study presents patients' and clinicians' attitudes toward hypothetical scenarios for a trial of pre-authorized reduction of opioids. The findings indicate positive attitudes and the relevance of engaging patients with effective decision-making processes.

Patient outcomes after opioid dose reduction among patients with chronic opioid therapy

ABSTRACT

The net effects of prescribing initiatives that encourage dose reductions are uncertain. We examined whether rapid dose reduction after high-dose chronic opioid therapy (COT) associates with suicide, overdose, or other opioid-related adverse events. This retrospective cohort study included Oregon Medicaid recipients with high-dose COT. Claims were linked with prescription data from the prescription drug monitoring program and death data from vital statistics, 2014 to 2017. Participants were placed into 4 mutually exclusive dose trajectory groups after the high-dose COT period, and Cox proportional hazard models were used to examine the effect of dose changes on patient outcomes in the following year. Of the 14,596 high-dose COT patients, 4191 (28.7%) abruptly discontinued opioid prescriptions, 1648 (11.3%) reduced opioid dose before discontinuing, 6480 (44.4%) had a dose reduction but never discontinued, and 2277 (15.6%) had a stable or increasing dose. Discontinuation, whether abrupt (adjusted hazard ratio [aHR] 3.63; 95% confidence interval [CI] 1.42-9.25) or with dose reduction (aHR 4.47, 95% CI 1.68-11.88) significantly increased risk of suicide compared with those with stable or increasing dose. By contrast, discontinuation or dose reduction reduced the risk of overdose compared with those with a stable or increasing dose (aHR 0.36-0.62, 95% CI 0.20-0.94). Patients with an abrupt discontinuation were more likely to overdose on heroin (vs. prescription opioids) than patients in other groups (P < 0.0001). Our study suggests that patients on COT require careful risk assessment and supportive interventions when considering opioid discontinuation or continuation at a high dose.

Bivalent Conjugate Vaccine Induces Dual Immunogenic Response That Attenuates Heroin and Fentanyl Effects in Mice

Opioid use disorders and fatal overdose due to consumption of fentanyl-laced heroin remain a major public health menace in the United States. Vaccination may serve as a promising potential remedy to combat accidental overdose and to mitigate the abuse potential of opioids. We previously reported the heroin and fentanyl monovalent vaccines carrying, respectively, a heroin hapten, 6-AmHap, and a fentanyl hapten, para-AmFenHap, conjugated to tetanus toxoid (TT). Herein, we describe the mixing of these antigens to formulate a bivalent vaccine adjuvanted with liposomes containing monophosphoryl lipid A (MPLA) adsorbed on aluminum hydroxide. Immunization of mice with the bivalent vaccine resulted in IgG titers of >105 against both haptens. The polyclonal sera bound heroin, 6-acetylmorphine, morphine, and fentanyl with dissociation constants (Kd) of 0.25 to 0.50 nM. Mice were protected from the anti-nociceptive effects of heroin, fentanyl, and heroin +9% (w/w) fentanyl. No cross-reactivity to methadone and buprenorphine was observed in vivo. Naloxone remained efficacious in immunized mice. These results highlighted the potential of combining TT-6-AmHap and TT-para-AmFenHap to yield an efficacious bivalent vaccine that could ablate heroin and fentanyl effects. This vaccine warrants further testing to establish its potential translatability to humans.

Claims-based measures of prescription opioid utilization: A practical guide for researchers

BACKGROUND

Given the increased attention to the opioid epidemic and the role of inappropriate prescribing, there has been a marked increase in the number of studies using claims data to study opioid use and policies designed to curb misuse. Our objective is to review the medical literature for recent studies that use claims data to construct opioid use measures and to develop a guide for researchers using these measures.

METHODS

We searched for articles relating to opioid use measured in health insurance claims data using a defined set of search terms for the years 2014-2020. Original research articles based in the United States that used claims-based measures of opioid utilization were included and information on the study population and measures of any opioid use, quantity of opioid use, new opioid use, chronic opioid use, multiple providers, and overlapping prescriptions was abstracted.

RESULTS

A total of 164 articles met inclusion criteria. Any opioid use was the most commonly included measure, defined by 85 studies. This was followed by quantity of opioids (68 studies), chronic opioid use (53 studies), overlapping prescriptions (28 studies), and multiple providers (8 studies). Each measure contained multiple, distinct definitions with considerable variation in how each was operationalized.

CONCLUSIONS

Claims-based opioid utilization measures are commonly used in research, but definitions vary significantly from study to study. Researchers should carefully consider which opioid utilization measures and definitions are most appropriate for their study and recognize how different definitions may influence study results.

Long-term opioid therapy tapering: Trends from 2014 to 2018 in a Midwestern State

BACKGROUND

The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain (Guideline hereafter) emphasized tapering patients from long-term opioid therapy (LTOT) when the harms outweigh the benefits.

METHODS

To examine tapering from LTOT before and after the Guideline release, we conducted a retrospective cohort study of adults with high-dose LTOT (mean of >50 Morphine Milligram Equivalents [MME]/day) from 2014 to 2018 from one Midwest state's Health Information Exchange. We identified tapering (dose reductions in mean MME/day greater than 15%, 30%, 50%) and rapid discontinuation episodes (reduction to zero MME/day) over a 6-month follow-up period relative to a 3-month baseline period. We used segmented regressions to estimate outcomes adjusted for time trends and relevant state laws limiting opioid prescribing.

RESULTS

The Guideline release was associated with statistically significant immediate increase in the patient likelihood of experiencing tapering (15%: 1.8% point [95% confidence interval (CI): 1.2-2.6; 30%: 1.4% point, 95% CI: 0.7-2.2; 50%: 0.8% point, 95% CI: 0.2-1.4) and rapid discontinuation episodes (0.006% point, 95% CI: 0.001-0.01). After the Guideline release, the patient likelihood of tapering increased over time (15%: 0.4% point/month, 95% CI: 0.3-0.5; 30%: 0.3% point/month, 95% CI:0.2-0.4; 50%: 0.3% point/month, 95% CI: 0.2-0.3; rapid discontinuation: 0.01% point/month, 95% CI: 0.007-0.01). Tapering and rapid discontinuation trends was similar among gender and race categories.

CONCLUSION

The Guideline may be a useful tool in altering opioid prescribing practices, particularly for patients on shorter durations of LTOT.

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids

Importance

Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis.

Objective

To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids.

Design, Setting, and Participants

Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion.

Exposures

Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period.

Main Outcomes and Measures

Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity.

Results

The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21).

Conclusions and Relevance

Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

'First Do No Harm': physician discretion, racial disparities and opioid treatment agreements

The increasing use of opioid treatment agreements (OTAs) has prompted debate within the medical community about ethical challenges with respect to their implementation. The focus of debate is usually on the efficacy of OTAs at reducing opioid misuse, how OTAs may undermine trust between physicians and patients and the potential coercive nature of requiring patients to sign such agreements as a condition for receiving pain care. An important consideration missing from these conversations is the potential for racial bias in the current way that OTAs are incorporated into clinical practice and in the amount of physician discretion that current opioid guidelines support. While the use of OTAs has become mandatory in some states for certain classes of patients, physicians are still afforded great leeway in how these OTAs are implemented in clinical practice and how their terms should be enforced. This paper uses the guidelines provided for OTA implementation by the states of Indiana and Pennsylvania as case studies in order to argue that giving physicians certain kinds of discretion may exacerbate racial health disparities. This problem cannot simply be addressed by minimising physician discretion in general, but rather by providing mechanisms to hold physicians accountable for how they treat patients on long-term opioid therapy to ensure that such treatment is equitable.

Longitudinal Dose Trajectory Among Patients Tapering Long-Term Opioids

OBJECTIVE

To evaluate the dose trajectory of new opioid tapers and estimate the percentage of patients with sustained tapers at long-term follow-up.

DESIGN

Retrospective cohort study.

SETTING

Data from the OptumLabs Data Warehouse® which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States.

SUBJECTS

Patients prescribed stable, higher-dose opioids for ≥12 months from 2008 to 2018.

METHODS

Tapering was defined as ≥15% relative reduction in average MME/day during any of six overlapping 60-day periods in the initial 7 months of follow-up after the period of stable baseline dosing. Average monthly dose was ascertained during consecutive 60-day periods up to 16 months of follow-up. Linear regression estimated the geometric mean relative dose by tapering status and follow-up duration. Poisson regression estimated the percentage of tapered patients with sustained dose reductions at follow-up and patient-level predictors of failing to sustain tapers.

RESULTS

The sample included 113,618 patients with 203,920 periods of stable baseline dosing (mean follow-up = 13.7 months). Tapering was initiated during 37,170 follow-up periods (18.2%). After taper initiation, patients had a substantial initial mean dose reduction (geometric mean relative dose .73 [95% CI: .72-.74]) that was sustained through 16 months of follow-up; at which point, 69.8% (95% CI: 69.1%-70.4%) of patients who initiated tapers had a relative dose reduction ≥15%, and 14.2% (95% CI: 13.7%-14.7%) had discontinued opioids. Failure to sustain tapers was significantly less likely among patients with overdose events during follow-up (adjusted incidence rate ratio [aIRR]: .56 [95% CI: .48-.67]) and during more recent years (aIRR: .93 per year after 2008 [95% CI: .92-.94]).

CONCLUSIONS

In an insured and Medicare Advantage population, over two-thirds of patients who initiated opioid dose tapering sustained long-term dose reductions, and the likelihood of sustaining tapers increased substantially from 2008 to 2018.

STRategies to Improve Pain and Enjoy life (STRIPE): Protocol for a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy

High-dose, long-term opioid therapy (LtOT) is associated with risk for serious harms. Rapid opioid discontinuation may lead to increased pain, psychological distress, and illicit opioid use, but gradual, supported opioid taper may reduce these risks. We previously demonstrated that an opioid taper support and pain coping skills training intervention reduced opioid dose more than usual care (43% vs 19% dose reduction from baseline), with no increase in pain intensity and a significant reduction in activity interference. We aim to adapt and test this intervention in the Kaiser Permanente Washington healthcare system with STRategies to Improve Pain and Enjoy life (STRIPE), a pragmatic, randomized trial. Our goal was to randomize 215 participants on moderate-high dose (≥40 morphine milligram equivalent/day) LtOT to either cognitive-behavioral therapy-based pain coping skills training involving 18 telephone sessions over 52 weeks with optional opioid taper support or usual care. Data are collected from electronic health records, claims, and self-report. The primary outcomes are mean daily opioid dose and the pain intensity, interference with enjoyment of life, and interference with general activity (PEG) score at 12 months (primary time point) and 6 months (secondary time point). Secondary outcomes include having ≥30% opioid dose reduction from baseline, and patient-reported problem opioid use, opioid-related difficulties, pain self-efficacy, opioid craving, global impression of change, and anxiety and depressive symptoms at 6 and 12 months. If effective, this treatment could reduce opioid exposure and associated risks to patients, families, and communities while offering patients an alternative for managing pain. Trial registration: The study was first registered at Clinicaltrials.gov on November 16, 2018 (identifier: NCT03743402).

Changes in Initial Opioid Prescribing Practices After the 2016 Release of the CDC Guideline for Prescribing Opioids for Chronic Pain

IMPORTANCE

The Centers for Disease Control and Prevention (CDC) released the "Guideline For Prescribing Opioids For Chronic Pain" (hereafter, CDC guideline) in 2016, but its association with prescribing practices for patients who are opioid naive is unknown.

OBJECTIVE

To estimate changes in initial prescribing rates, duration, and dosage practices to patients who are opioid naive after the release of the CDC guideline.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used 6 sequential cohorts to estimate preguideline trends in prescribing among patients who were opioid naive, project that trend forward, and compare it with postguideline prescribing practices. Participants included commercially insured adults without current cancer or hospice care diagnoses and with no past-year opioid claims in the US from 2011 to 2017. All adjusted models were controlled for patient demographics and state-fixed effects. Data were analyzed from January 2020 to May 2021.

EXPOSURES

The release of the CDC guideline.

MAIN OUTCOMES AND MEASURES

Indicators of any opioid prescription fills during a 9-month period, the number of days' supply of the initial prescription, and the binary indicator of whether the initial prescription was for 50 or more morphine milligram equivalents (MMEs) per day.

RESULTS

There were 12 870 612 eligible unique patients across cohorts (mean [SD] age in 2016, 51.2 [18.7] years; 6 553 458 [50.9%] women); and the mean (SD) age of the cohorts increased annually, from 48.7 (17.9) years in the April 2011 to December 2012 cohort to 51.9 (19.2) years in the April 2016 to December 2017 cohort. The postguideline prescribing prevalence was 532 962 of 5 834 088 individuals (9.1%), which exceeded that projected from the preguideline trend, estimated at 9.0% (95% CI, 9.0%-9.1%). Among patients receiving prescriptions during follow-up, adjusted mean days' supply was 4.7% (95% CI, 4.3%-5.1%) lower in the first year after release of the guideline and 9.8% (95% CI, 9.3%-10.3%) lower in the second year after release, compared with the expected rate from the preguideline trend. The adjusted odds of receiving a high-dose (ie, ≥50 MME/d) initial prescription were lower in the first year (odds ratio, 0.97; 95% CI, 0.96-0.98) and in the second year (odds ratio, 0.94; 95% CI, 0.93-0.96) after the release of the CDC guideline compared with the odds expected from the preguideline trend.

CONCLUSIONS AND RELEVANCE

This cohort study found that patients who were opioid naive continued to initiate opioid therapy after the release of opioid prescribing guidelines by the CDC, but trends in prescribing duration reversed and decreased, after increasing in each of 4 preguideline cohorts examined. High-dose prescribing rates were already decreasing, but those trends accelerated after the CDC guideline release. These results suggest that nonmandatory, evidence-based guidelines from trusted sources were associated with prescribing practices. Guideline-concordant care has potential to improve pain management and reduce opioid-related harms.

Abrupt Discontinuation of Long-term Opioid Therapy Among Medicare Beneficiaries, 2012-2017

BACKGROUND

With mounting pressure to reduce opioid use, concerns exist about abrupt withdrawal of treatment for the millions of Americans using long-term opioid therapy (LTOT). However, little is known about how patients are tapered from LTOT nationally.

OBJECTIVE

Measure national patterns of LTOT discontinuation and adherence to recommended tapering speed.

DESIGN

Observational study of Medicare Part D from 2012 to 2017.

PARTICIPANTS

Using claims for a 20% sample of Medicare beneficiaries, we included patients on LTOT for 1 year or more, defined as those with ≥ 4 consecutive quarters with > 60 days of opioids supplied in each quarter.

MAIN MEASURES

Our primary outcome was discontinuation of LTOT, defined as at least 60 consecutive days without opioids supplied. We additionally examined whether discontinuation of LTOT was "tapered" or "abrupt" by comparing LTOT users' daily MME dose in the last month of therapy to their average daily dose in a baseline period of 7 to 12 months before discontinuation. By the last month of therapy, patients with "abrupt" discontinuation had a < 50% reduction in their average daily dose at baseline.

KEY RESULTS

From 2012 to 2017, there were 258,988 LTOT users, 17,617 of whom discontinued therapy. Adjusted rates of LTOT discontinuation increased from 5.7% of users in 2012 to 8.5% in 2017, a 49% relative increase (p < 0.001). There was a similar increase in annual discontinuation rate for LTOT users on lower (26-90 MME, 5.8% to 8.7%, p < 0.001) vs. higher doses (> 90 MME, 5.3% to 7.7%, p < 0.001). The majority of LTOT discontinuations were stopped abruptly, and increased over time (70.1% to 81.2%, 2012-2017, p < 0.001).

CONCLUSIONS

Medicare beneficiaries on LTOT were increasingly likely to have their therapy discontinued from 2012 to 2017. The vast majority of discontinuing users, even those on high doses, had less than 50% reduction in dose, which is inconsistent with existing guidelines.