IMPORTANCE Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis.OBJECTIVE To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids.DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean Ն50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion.EXPOSURES Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period.MAIN OUTCOMES AND MEASURES Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity. RESULTSThe final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 6.3 overdose events per 100 person-years compared with 4.9 events per 100 person-years in non-tapered periods (adjusted incidence rate difference, 1.4 per 100 person-years [95% CI, 0.7-2.1]; aIRR, 1.28 [95% CI, 1.15-1.43]). Tapering was associated with an adjusted incidence rate of 7.4 mental health crisis events per 100 person-years compared with 4.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 3.1 per 100 person-years [95% CI, 2.1-4.1]; aIRR, 1.74 [95% CI, 1.50-2.01]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.05 for overdose (95% CI, 1.03-1.08) and of 1.14 for mental health crisis (95% CI, 1.11-1.17).CONCLUSIONS AND RELEVANCE Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

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Key PointsQuestionHow 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?FindingsThis 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 patents undergoing tapering had a maximum dose reduction rate exceeding 10% per week.MeaningA substantial percentage of patients prescribed long-term opioid therapy are undergoing tapering, often at rapid maximum rates.

Key Points Question Is opioid dose tapering associated with reduced longer-term risks of overdose, withdrawal, or mental health crisis in patients prescribed long-term opioids? Findings In this cohort study of 19 377 patients, in a posttaper period (beginning at least 12 months and extending up to 24 months after taper initiation) vs the pretaper period, the adjusted incidence rate ratios were 1.57 for overdose-withdrawal and 1.52 for a mental health crisis. Both were significant. Meaning These findings suggest that opioid dose tapering was associated increased risks of overdose-withdrawal and mental health crisis that persisted up to 2 years after taper initiation.