Is there a dose reduction in patients on stable opioid therapy, long-term overdose and mental health risks?
Researchers at the UC Davis Center for Health Policy and Research have studied the potential long-term risks of opioid dose reduction. They found that patients on stable but higher doses of opioid therapy, whose doses were reduced by at least 15%, had significantly higher levels of overdose and mental health crisis in the second year after the reduction compared with the period. before reduction.
Their study was published on June 13 JAMA Network Open.
Opioid therapy and stimulant to reduce the dose of painkillers
Changes in prescribing guidelines and regulatory policies driven by the rise in opioid-related deaths have led many physicians to reduce daily doses for patients on stable opioid therapy for chronic pain. The process of reducing the dose – called narrowing – is associated with worsening pain, opioid withdrawal symptoms and depressed mood in some patients.
A team of UC Davis Health researchers recently found an increased risk of overdose and mental health crisis within a year of dose reduction. Their research shows that patients undergoing reduction need significant support to safely reduce or stop opioids.
“While patients may struggle during the early decline period, we thought that many of them could stabilize with longer-term follow-up and have lower levels of overdose and mental health crisis once achieved. lower dose of opioids, “said Joshua Fenton, professor and deputy. chairman of research in the Department of Family and Community Medicine at UC Davis School of Medicine and lead author of the study. “Our findings show that for most patients with a reduction, the increased risk of overdose and mental health crisis persists for up to two years after gradual treatment is started.”
Pain management and dose risk
To make associations between dose reduction and changes in the risk of overdose and mental health visits, the researchers used a 10-year database (2008-2017) for more than 28,000 patients prescribed long-term opioids. They reviewed the records and medical and pharmacy claims for patients who were prescribed stable high doses of opioids (equivalent to at least 50 milligrams of morphine per day) and whose doses were reduced by at least 15%.
From this group of patients, they selected those who had at least one month of follow-up in the second year of the post-reduction period. They identified a total of 21,515 attenuating events for 19,377 patients.
These events include visits to the emergency department or hospitalization for a drug overdose, abstinence, or mental health crisis, such as depression, anxiety, or suicide attempts. The team compared the frequency of these events in the period before the gradual decline with those in the second year of follow-up after the start of the gradual decline.
“We used an innovative design of an observational study to understand patients’ experiences before and after opioid dose reduction. We compared the outcome before and after the reduction with patients serving as their own controls,” said Daniel Tancredi, co-author of the study. and a professor in the Department of Pediatrics at UC Davis Health. “This design has the advantage of controlling patient characteristics that may affect the relationship between reduction and adverse events.”
The study found that for every 100 patients, there were an average of 3.5 cases of overdose or withdrawal and 3 mental health crises during the period before the gradual decline, compared with 5.4 events and 4.4 crises in the 12-month period. 24 months after the reduction. This is a 57% increase in overdose or withdrawal cases and a 52% increase in mental health crises. The risks of reduction were greatest in patients with the highest starting doses.
“We found that the increased levels of overdose and mental health crisis observed in the first year after opioid dose reduction continued in the second year,” Fenton added.
Long-term follow-up and support for patients on reduced pain therapy
In 2018, the Ministry of Health and Human Services (HHS) issued guidelines to advise clinicians to closely monitor patients during reductions and provide psychosocial support. They recommended close monitoring and warned of the potential risks of rapid dose reduction, including withdrawal, switching to illicit opioids and psychological stress.
This new study highlighted the need for clinicians and patients to discuss dose reduction and to carefully weigh the risks and benefits of opioid continuation and reduction. Patients with a reduction will benefit from close monitoring and monitoring not only in the short term but also in the long term to ensure that they are coping well with lower doses.
“We hope this work will provide information on a more cautious approach to opioid dose reduction decisions,” Fenton said. “While our results show that all declining patients can benefit from monitoring and support for up to two years after the gradual reduction begins, patients who are prescribed higher doses can benefit from more intensive support and monitoring, especially for depression and suicide.
Other UC Davis Health contributors include Elizabeth Magan, Iraklis Eric Ceregunis, Guibo Son and Alicia Agnoli. The study is supported by a research loan from the University of California-OptumLabs, the Department of Family and Community Medicine at UC Davis and the Dean’s Office of UC Davis School of Medicine (Dean’s Scholarship in Women’s Health Research BIRCWH / K12).