Patient Outcomes Following Opioid Dose Reduction Among Patients with Chronic Opioid Therapy
Authors: Hallvik S. , El Ibrahimi S. , Johnston K. , Gedes J. , Leichtling G. , Todd Korthuis P. , Hartung D. 
Published: August 2020

Research Objective

The impact of prescribing initiatives that encourage dose reductions is still largely unknown. Our objective was to determine whether the degree of opioid dose reduction among patients with high‐dose chronic opioid treatment (COT) associates with suicide, opioid overdose, other opioid‐related adverse events, or buprenorphine fills.

Study Design

In this retrospective cohort study, we identified patients with COT in 2014 or 2015 with 12 months of follow‐up to determine opioid dose trajectory and an additional 12 months of follow‐up to identify outcomes. We characterized dose trajectories in 12 months after a period of COT as abrupt discontinuation, dose reduction with discontinuation, dose reduction without discontinuation, and no dose reduction or discontinuation. We also characterized the effect of patient demographics (age, race, gender, rural vs. urban), prescription profile during COT, and diagnoses of alcohol abuse, depression, or any drug abuse. Multivariate logistic regression was used to examine the effect of dose trajectories on suicide (fatal or non‐fatal), opioid overdose (fatal or non‐fatal), other adverse events, and buprenorphine fills in the following year. Other adverse events included a diagnosis of adverse effects, opioid abuse, opioid dependence, or unspecified opioid use diagnosed in outpatient, inpatient (hospital), or emergency department settings.

Population Studied

We studied 17,990 continuously enrolled Medicaid recipients in Oregon with high‐dose COT. All analyses used the Oregon Medicaid claims data linked with the Oregon Prescription Drug Monitoring Program (PDMP) and vital statistics data sets covering calendar years 2014 to 2017.

Principal Findings

In the 12 months after the high‐dose COT period, there were 1,328 (7.38%) individuals with an abrupt discontinuation, 2,953 (16.41%) with a dose reduction with discontinuation, 4,282 (23.8%) with a dose reduction without discontinuation, and 9,427 (52.40%) with no dose reduction or discontinuation. Patients who abruptly discontinued had the highest odds of fatal or nonfatal suicide (adjusted odds ratio (aOR) 12.1, 95% confidence interval (CI) 3.5, 41.6), fatal or nonfatal overdose (aOR 2.6, 95% CI 1.4, 4.7), or other adverse events (aOR 2.0, 95% CI 1.4, 2.7). Among those who had an opioid overdose, patients who discontinued opioid use after COT were more likely to overdose on heroin than those who did not discontinue opioid use (P < .0001). Among those with a suicide or opioid overdose event, patients with a dose reduction and discontinuation were more likely to experience a fatal event compared to those with an abrupt discontinuation or no discontinuation (P < .0001). Patients with a dose reduction and discontinuation were most likely to have filled at least one buprenorphine prescription during the follow‐up period (n = 177, 6.0%, P < .0001) when compared to all other dose trajectory groups.

Conclusions

Rapid dose reduction or discontinuation after COT increased the odds of suicide, overdose, or other adverse events, while the odds of each type of event were highest among those with an abrupt discontinuation.

Implications for Policy or Practice

Our study suggests that patients on high‐dose COT require careful risk assessment and supportive interventions when initiating opioid dose reduction or discontinuation.

Primary Funding Source

Centers for Disease Control and Prevention