Abrupt Discontinuation of Long-term Opioid Therapy Among Medicare Beneficiaries, 2012–2017

Abstract

BACKGROUND: With mounting pressure to reduce opioid use, concerns exist about abrupt withdrawal of treatment for the millions of Americans using long-term opioid therapy (LTOT). However, little is known about how patients are tapered from LTOT nationally. OBJECTIVE: Measure national patterns of LTOT discontinuation and adherence to recommended tapering speed. DESIGN: Observational study of Medicare Part D from 2012 to 2017. PARTICIPANTS: Using claims for a 20% sample of Medicare beneficiaries, we included patients on LTOT for 1 year or more, defined as those with ≥ 4 consecutive quarters with > 60 days of opioids supplied in each quarter. MAIN MEASURES: Our primary outcome was discontinuation of LTOT, defined as at least 60 consecutive days without opioids supplied. We additionally examined whether discontinuation of LTOT was "tapered" or "abrupt" by comparing LTOT users' daily MME dose in the last month of therapy to their average daily dose in a baseline period of 7 to 12 months before discontinuation. By the last month of therapy, patients with "abrupt" discontinuation had a < 50% reduction in their average daily dose at baseline. KEY RESULTS: From 2012 to 2017, there were 258,988 LTOT users, 17,617 of whom discontinued therapy. Adjusted rates of LTOT discontinuation increased from 5.7% of users in 2012 to 8.5% in 2017, a 49% relative increase (p < 0.001). There was a similar increase in annual discontinuation rate for LTOT users on lower (26-90 MME, 5.8% to 8.7%, p < 0.001) vs. higher doses (> 90 MME, 5.3% to 7.7%, p < 0.001). The majority of LTOT discontinuations were stopped abruptly, and increased over time (70.1% to 81.2%, 2012-2017, p < 0.001). CONCLUSIONS: Medicare beneficiaries on LTOT were increasingly likely to have their therapy discontinued from 2012 to 2017. The vast majority of discontinuing users, even those on high doses, had less than 50% reduction in dose, which is inconsistent with existing guidelines.

Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment

“…We explored baseline characteristics previously shown to be associated with opioid tapering, discontinuation, dose variability, or overdose mortality. 6 , 17 , 29 , 30 , 31 , 32 Demographic characteristics included age on the index date, sex, and race and ethnicity as reported by patients during visit registration and recorded in the EHR. Race and ethnicity, Medicaid coverage, and the calendar year of the index date were assessed because they could impact management decisions and the outcomes.…”

New Data on Opioid Dose Reduction—Implications for Patient Safety

“…To our view, a lack of consent does not compel a prescribing clinician to continue a treatment that they believe is actively harming that patient. However, that same clinician should proceed with reductions only after (1) documenting evidence of harm, (2) offering a plan to mitigate harm from the reduction, and (3) telling the patient what criteria will be used to decide whether the taper has failed or succeeded.…”

“…Unsurprisingly, dose reductions and stoppage have become more common in recent years. 3 Some retrospective studies found an association between dose reduction and poor outcomes, such as death by overdose, suicide, or mental health crisis, after comparing patients who underwent such reductions and others who did not. One limitation to such reports is that people who underwent reduction could have differed in important ways from those who did not.…”

Comparative Effectiveness of Opioid Tapering or Abrupt Discontinuation vs No Dosage Change for Opioid Overdose or Suicide for Patients Receiving Stable Long-term Opioid Therapy

“… 5 , 6 , 7 These efforts were associated with declines in opioid prescribing and dosages in the United States. 8 , 9 , 10 …”

“…[5][6][7] These efforts were associated with declines in opioid prescribing and dosages in the United States. [8][9][10] A systematic review of opioid tapering studies found low-quality evidence favoring tapering in improving pain intensity, function, and quality of life. 11 Meanwhile, increasing reports of patients experiencing adverse effects from forced opioid tapers, including opioid withdrawal, increasing pain, decreasing function, and suicidality, has led pain experts, authors of the CDC guideline, and the US Food and Drug Administration to issue warnings of the harms of rapid opioid tapers.…”