Aggressive Opioid Tapering Is Associated With Long Term Harms, Study Shows

Patients who undergo aggressive opioid tapering are often hospitalized for overdose, withdrawal or mental health crises

A recent study out of the University of California found that aggressive tapering of opioids resulted in long-term risk of substance misuse, overdose, and mental health crisis. Although these risks are inherent in any opioid tapering, researchers believed that they were short-lived. This latest study demonstrates that these effects can persist for up to 2 years. 

Researchers gathered data for the study from a cohort of 19,377 adults who underwent opioid tapering between 2008 and 2017. All patients had previously been on a stable dose of at least 50 morphine milligram equivalents (MME) of an opioid for 12 months or more, and had at least one follow-up visit at least 12 months after the taper was initiated. “Tapering” was defined as at least a 15% dose reduction relative to the patient’s baseline during 6 overlapping 60-day periods. Adverse events were tracked using emergency room and inpatient hospital records showing a primary diagnosis of drug overdose, alcohol intoxication, drug withdrawal,  anxiety/depression, suicide attempt or intentional self harm. The study participants served as their own controls as the researchers compared the number of incidents during the 12 months pre-taper and 12 months post.

The researchers, led by Joshua J. Fenton’, M.D. M.P.H.,deliberately structured the study to allow sufficient time for the acute effects of the opioid taper to disappear.. Nonetheless, they found that the incidence of withdrawal, overdose and mental health crisis were significantly higher 12 months after the taper was initiated than they were in the 12 months before. Adverse outcomes were highest in the patients whose pre-taper opioid dose was highest (300 MMEs or more), and whose dose after the taper was 50%-85% or 85%-114% of their pre-taper dose. Patients who successfully discontinued opioids or were on a final dose of between 1% and 49% of their baseline had a lower incidence of adverse events. 

Why Taper Opioids?

As most of us are well aware, an epidemic of opioid-related deaths has plagued the U.S. since the mid-1990s, when Purdue Pharma began aggressively marketing its long acting opioid Oxycontin to providers nationwide. By 1999, millions of Americans had been prescribed Oxycontin for chronic pain, and the death toll from overdose began to rise. The trend has continued unabated ever since — between April 2020 and April 2021, over 100,000 overdose deaths occurred in the U.S., a year-over-year increase of nearly 20,000 deaths. Since about 2010, heroin and, more recently, illegally manufactured fentanyl have replaced prescription drugs as the number one cause of overdose death. 

With opioid deaths are at an all time high in the US, many chronic pain patients are getting less than optimal care
Credit: columbiapsychiatry.org

The U.S. has had a mixed and often confusing response to the opioid epidemic. But one of its major policy decisions was the issuance of the CDC Guidelines for Prescribing Opioids for Chronic Pain, in 2016. The guidelines were extensive, but the overriding message to clinicians was that high-dose opioids (greater than 90 MME/day) should be avoided, even in patients with severe chronic pain. The agency also urged clinicians to begin tapering even long-term pain patients on stable but high doses of opioids unless the benefits of continuing the therapy clearly outweighed the potential harms. 

Well meaning as it was, this guidance, combined with a spate of state rules and regulations that set opioid prescribing limits and threatened providers with severe penalties for failing to adhere to them, had a chilling effect. Believing they had no choice, doctors began aggressively  tapering opioids in long-term pain patients, many of whom — unable to tolerate the lower doses — turned to illicit drugs and even suicide. By 2019, protests  from pain patients and physicians treating them led the CDC to issue a statement clarifying its guidance and urging clinicians to apply a more individualized approach. Also in 2019, the Department of Health and Human Services issued new guidelines to help physicians structure an opioid taper, enlist buy-in from patients, and assess patients coming off opioids for symptoms of depression, anxiety, withdrawal or substance misuse.

What This  Study Shows

The U.S. is currently revisiting its approach to the opioid crisis, focusing on better funding for state health departments, increasing access to medication-assisted treatment (methadone, buprenorphine and naltrexone), and providing greater access to emergency overdose treatment (naloxone) to help reduce harms. Still, many physicians continue the practice of aggressively tapering opioids without fully understanding the risk. This study highlights the very real dangers inherent in opioid tapering, especially in patients who have been on high but stable doses of opioids for months or years. By showing that these dangers persist long term, the authors demonstrate that follow-up and careful monitoring of chronic pain patients for up to 24 months after reaching a stable post-taper opioid dose is essential to preventing further harm and helping them lead productive lives.