Opioid Tapering vs No Dosage Change for Suicide or Opioid Overdose Short-Term

Although a small absolute increase in risk for overdose or suicide linked with opioid tapering compared with stable opioid dosage is observed, there is no evidence that mandatory dosage tapering for individuals on stable long-term opioid dosage (without opioid misuse) will reduce short-term suicide or overdosing, according to study findings published recently in JAMA Network Open.

Recent indications suggest opioid dosage tapering as a strategy to reduce suicide and overdosing associated with long-term opioid therapy lack sufficient supporting evidence. The researchers sought to identify the association of abrupt discontinuation or opioid tapering with opioid suicide and overdosing events for patients treated with stable long-term opioid therapy who have no evidence of opioid misuse.

They conducted a comparative effectiveness study using US commercial insurance or Medicare Advantage claims of individuals at least 18 years of age treated with stable long-term opioid therapy without evidence of opioid misuse from January 2010 through December 2018. Interventions included abrupt discontinuation, tapering (dosage reduction ≥15%), and stable dosage. The primary endpoint was time to suicide event or opioid overdose identified over 11 months of follow-up from the International Classification of Diseases, Ninth Revision and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes in medical claims.

Researchers identified a cohort of 199,836 individuals (mean age 56.9±12.4 years; 57.6% between 45 and 64 years; 54.9% women), experienced 415,123 long-term opioid therapy episodes of which 87.1% were considered stable, 11.1% evaluated as a taper, and 1.8% considered abrupt discontinuation. They noted that adjusted cumulative incidence of suicide events or opioid overdose 11 months after baseline showed stable dosage strategy 0.96% (95% CI, 0.92%-0.99%), tapered dosage strategy 1.10% (95% CI, 0.99%-1.22%), and abrupt discontinuation strategy 1.28% (95% CI, 0.93%-1.38%).

They calculated the risk difference between abrupt discontinuation and a stable dosage was 0.33% (95% CI, −0.03% to 0.74%), and the risk difference between a taper and a stable dosage was 0.15% (95% CI, 0.03%-0.26%). They found similar results using the per-protocol approach.

Study limitations include using only commercially insured individuals without evidence of opioid misuse prior to tapering limits generalizability, tapering being inferred from observed dosage trajectories, unmeasured confounding due to the observational nature, and suicide or overdose events that didn’t involve insurance claims were not accounted for.

They noted their study identified a small absolute increase in risk for suicide and overdosing associated with opioid tapering compared with a stable opioid dosage, but researchers concluded that, “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.”

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.