Opioid prescription doses increasingly tapered, often too rapidly

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Stigma and safety fears have made daily dose tapering of opioid prescriptions more common. Research from the University of California – Davis – shows tapering can occur at rates as much as six times higher than recommended, putting patients at risk of withdrawal, uncontrolled pain or mental health crises.

The study – “Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017” – was published in JAMA Network Open. The results were also presented at the 16-19 November North American Primary Care Research Group meeting in Toronto.

“Tapering plans should be based on the needs and histories of each patient and adjusted as needed to avoid adverse outcomes,” said study author Alicia Agnoli, assistant professor of family and community medicine.

“Unfortunately, a lot of tapering occurs due to policy pressures and a rush to get doses below a specific and sometimes arbitrary threshold. That approach can be detrimental in the long run.”

According to material from the University of California – Davis Health – published in ScienceDaily, in 2016 the US Centers for Disease Control and Prevention (CDC) recommended dose tapering, or a slow reduction in prescription opioid doses over time, if the risks of continuing opioids outweigh the benefits.

That point in time is usually when a patient is taking 90 morphine milligram equivalents – or MMEs – each day, and that dose is no longer reducing pain or improving daily functions. The CDC advises a slow decrease of 10% MMEs per month.

The study team set out to examine trends in opioid dose tapering and if tapering rates were consistent with CDC recommendations.

“We wanted to understand how often opioid dose tapering happens, how rapidly patients’ doses were being reduced when tapering, and which patients were more likely to have doses tapered,” said lead author Joshua Fenton, professor of family and community medicine.

Tapering faster than recommended

Fenton and Agnoli evaluated medical and pharmacy claims and enrolment records for more than 100,000 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities and locations across the US.

They focused on individuals whose opioid doses were stable for at least a year and identified tapering patients as those with a 15% or more reduction in daily MMEs during a seven-month follow-up period.

They found that dose tapering became more common throughout the study period of 2008-2017, with the biggest jump following the CDC’s 2016 prescribing guidelines. Tapering increased from 10.5% to 13.7% from 2008 to 2015, and from 16.2% to 22.4% from 2016 to 2017. Tapering was much more common in patients prescribed higher opioid dosages.

They also found that the rate of dose reduction often was well beyond the CDC’s recommendation of 10% per month. The average reduction overall was 27.6% per month. Nearly 20% of patients tapered at a rate of 40% per month, and 5% tapered at a rate faster than 60% per month.

The 2016 policy could have been misinterpreted, leading many prescribers and health systems to insist on faster-than-recommended tapering, according to Agnoli.

“There is definitely a lot of pressure to reduce opioid use among patients, but there also is a need for more training and guidance for prescribers on how to help them safely do so,” Agnoli said.

Women and tapering

Fenton and Agnoli also identified patient variables associated with tapering and uncovered an interesting difference in tapering rates based on sex.

While men have much higher rates of opioid use disorder and adverse outcomes related to opioids, women were more likely than men to have their opioid doses tapered.

“We think this has a lot to do with the gender dynamics of pain management and the physician-patient relationship,” Agnoli said. “How women experience pain and discuss pain with their physicians is perhaps very different than men.

“There also could be some sex bias in terms of the patients that physicians choose to initiate conversations with about dose reduction.”

Minimising tapering risks

The researchers hope to build on this work to inform best practices for safe decision-making around dose reduction for all patients prescribed opioids.

“Ultimately, we want to clarify the effects of tapering on patients and how to help them taper to maximise benefits and minimise risks,” Fenton said. “We expect this line of research will have important implications for how physicians manage and monitor patients who are undergoing opioid tapering.”

Collaborators on the research were Guibo Xing, Daniel Tancredi, Anthony Jerant and Elizabeth Magnan of UC Davis Health, and Lillian Hang and Aylin Altan of OptumLabs in Minneapolis.

Their study was supported by UC Davis Health and OptumLabs and is available online. Materials were provided by the University of California – Davis Health.

Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017

JAMA Network Open, 15 November 2019

Authors

Joshua J Fenton, Alicia L Agnoli, Guibo Xing, Lillian Hang, Aylin E Altan, Daniel J Tancredi, Anthony Jerant and Elizabeth Magnan.

Key points

Question: How often are patients who are prescribed long-term opioids undergoing tapering of their daily doses, and how often do patients undergo a rapid taper rate?

Findings: This cohort study found that, among 100 031 patients with commercial or Medicare Advantage insurance who were using long-term opioids, the annual percentage undergoing tapering of their daily dosage increased from 10.5% in 2008 to 22.4% in 2017. Tapering was significantly more likely among women and patients with higher baseline opioid doses, and 18.8% of patients undergoing tapering had a maximum dose reduction rate exceeding 10% per week.

Meaning: A substantial percentage of patients prescribed long-term opioid therapy are undergoing tapering, often at rapid maximum rates.

Abstract

Importance: A 2016 Centers for Disease Control and Prevention prescribing guideline cautioned against higher-dose long-term opioid therapy and recommended tapering daily opioid doses by approximately 10% per week if the risks outweigh the benefits. Warnings have since appeared regarding potential hazards of rapid opioid tapering.

Objectives: To characterise US trends in opioid dose tapering among patients prescribed long-term opioids from 2008 to 2017 and identify patient-level variables associated with tapering and a more rapid rate of tapering.

Design, setting and participants: This retrospective cohort study used deidentified medical and pharmacy claims and enrolment records for 100 031 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races/ethnicities, and geographical regions across the United States.

Adults with stable, higher-dosage (mean, ≥50 morphine milligram equivalents [MMEs]/d) opioid prescriptions for a 12-month baseline period and 2 or more months of follow-up from 1 January 2008, to 31 December 2017, were included in the study.

Main outcomes and measures: Tapering was defined as 15% or more relative reduction in mean daily MME during any of 6 overlapping 60-day windows within a 7-month follow-up period. The rate of tapering was computed as the maximum monthly percentage dose reduction.

Results: Among the 100 031 participants (53 452 [53.4%] women; mean [SD] age, 57.6 [11.8] years), from 2008 to 2015, the age- and sex-standardised percentage of patients tapering daily opioid doses increased from 10.5% to 13.7% (adjusted incidence rate ratio [aIRR] per year, 1.05 [95% CI, 1.05-1.06]) before increasing to 16.2% in 2016 and 22.4% in 2017 (aIRR in 2016-2017 vs 2008-2015, 1.20 [95% CI, 1.16-1.25]). 

Patient-level covariates associated with tapering included female sex (aIRR, 1.13 [95% CI, 1.10-1.15]) and higher baseline dose (aIRR for ≥300 MMEs/d vs 50-89 MMEs/d, 2.57 [95% CI, 2.48-2.65]).

Among patients tapering daily opioid doses, the mean (SD) maximum dose reduction was 27.6% (17.0%) per month, and 18.8% of patients had a maximum tapering rate exceeding 40% per month (ie, faster than 10% per week). More rapid dose reduction was associated with 2016-2017 vs 2008-2015 (adjusted difference, 1.4% [95% CI, 0.8%-2.1%]) and higher baseline dose (adjusted difference, 2.7% [95% CI, 2.2%-3.3%] for 90-149 vs 50-89 MMEs/d).

Conclusions and relevance: Patients using long-term opioid therapy are increasingly undergoing dose tapering, particularly women and those prescribed higher doses; in addition, dose tapering has become more common since 2016. Many patients undergoing tapering reduce daily doses at a rapid maximum rate.

Opioid prescription doses are increasingly being tapered, often more rapidly than recommended

Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017


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