Opioid therapy is complex. In recent years, a rise in opioid-related deaths and changing prescribing guidelines and regulatory policies have led many physicians to reduce daily doses for patients prescribed stable opioid therapy for chronic pain.

Some patients have reported that this dose reduction processcalled tapering has been difficult, sometimes involving worsened pain, symptoms of opioid withdrawal and depressed mood.

In a study published Aug. 3 in JAMA, a team of UC Davis Health researchers examined the potential risks of opioid dose tapering. Their study found that patients on stable opioid therapy who had their doses tapered had significantly higher rates of overdose and mental health crisis, compared to patients without dose reductions.

"Prescribers are really in a difficult position. There are conflicting desires of ameliorating pain among patients while reducing the risk of adverse outcomes related to prescriptions," said Alicia Agnoli, assistant professor of Family and Community Medicine at UC Davis School of Medicine and first author on the study. "Our study shows an increased risk of overdose and mental health crisis following dose reduction. It suggests that patients undergoing tapering need significant support to safely reduce or discontinue their opioids."

De-prescribing opioids for patients on long-term therapy

The study used enrollment records and medical and pharmacy claims for 113,618 patients prescribed stable higher opioid doses (the equivalent of at least 50 morphine milligrams per day) for a one-year baseline period and at least two months of follow-up.

It looked at emergency department visits or inpatient hospital admissions for any drug overdose, alcohol intoxication, or drug withdrawal and for mental health crisis events such as depression, anxiety, or suicide attempts.

The researchers compared outcomes for patients after dose tapering to those for patients before or without tapering. They found a 68% increase in overdose events and a doubling of mental health crises among tapered as compared to non-tapered patients. The risks of tapering were greater in patients who had faster dose reductions and higher baseline doses.

To taper or not to taper

Guidelines from the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) advise clinicians to monitor patients carefully during tapering and provide psychosocial support. They caution about the potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress.

"Our study results support the recent federal guidelines for clinicians considering opioid dose reduction for patients," said Joshua Fenton, professor and Vice Chair of Research in the Department of Family and Community Medicine and senior author on the study. "But I fear that most tapering patients aren't receiving close follow-up and monitoring to make sure they're coping well on lower doses."

The researchers emphasized the need for clinicians and patients to carefully weigh the risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy.

"We hope that this work will inform a more cautious and compassionate approach to decisions around opioid dose tapering," Agnoli said. "Our study may help shape clinical guidelines on patient selection for tapering, optimal rates of dose reduction, and how best to monitor and support patients during periods of dose transition."