Rapid Opioid Dose Tapering Linked with Heightened Overdose, Mental Health Crisis Risk

Dose tapering for patients who have been prescribed long-term, high-dose opioid therapy for pain has been associated with a heightened risk for overdose and/or mental health crisis, according to a study by researchers at the University of California, Davis.

Findings were published last week by JAMA Network.

The study looked at data for more than 113,000 patients who had been prescribed stable, high-dose opioid therapy (the equivalent of at least 50 morphine milligrams per day) for at least 1 year and at least 2 months of follow-up. Within 12 months after dose tapering, patients were found to have adjusted incidence rates of overdose and mental health crisis that were higher than those before or without tapering. Overdose events increased by 68%, and mental health crises doubled in tapering patients vs. non-tapering patients. Faster dose reductions and higher baseline doses were associated with greater risks among tapering patients.

“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,” Alicia Agnoli, assistant professor of Family and Community Medicine at UC Davis School of Medicine and first author on the study, said in a news release. “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.”

Withdrawal, a transition to illicit opioids and psychological distress are among the potential hazards associated with rapid opioid dose reduction, the researchers noted, adding that tapering patients should receive close follow-up and monitoring to ensure they are coping well, and that clinicians and patients should discuss the risks and benefits of opioid continuation and tapering.

“We hope that this work will inform a more cautious and compassionate approach to decisions around opioid dose tapering,” Agnoli said in the release. “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.”