Opioid medication discontinuation and risk of adverse opioid-related health care events

Mark, Tami L.; Parish, William J.

doi:10.1016/j.jsat.2019.05.001

Cited by 144 publications

(156 citation statements)

References 13 publications

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“…Those treated with opioids for 31-90 days had a hazard ratio of 2.4 for death from overdose after stopping opioid treatment (2.8 for death from overdose or suicide). Our study reinforces the importance of the first three months after stopping opioid treatment, extending the high risk period from 77 days17 to at least 100 days.…”

Section: Discussionsupporting

confidence: 84%

“…Previous studies focused mostly on smaller regional samples of patients treated with high doses of opioids or for long periods of time,1718 whereas our study used national data from the Veterans Health Administration and included all patients prescribed opioids. All patients exposed to opioids had an increased risk of death from overdose or suicide after starting or stopping treatment with opioids.…”

Section: Discussionmentioning

confidence: 99%

“…Stopping treatment for at least three months (that is, 0 mg of morphine equivalence) mitigated the risk 16. In an analysis of Vermont Medicaid data between 2013 and 2017 of 494 patients treated with high doses of opioids for long periods of time who stopped taking opioids, researchers found that almost half had been admitted to hospital or visited the emergency department for an opioid or substance use related event, after they had stopped treatment 17. The impact of stopping treatment in 572 patients on long term treatment with opioids was examined in a safety net primary care clinic in Seattle with opioid registry data from 2010 to 2015.…”

Section: Introductionmentioning

confidence: 99%

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Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation

Oliva

Bowe

Manhapra

et al. 2020

BMJ

171

164

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Objective To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. Design Observational evaluation. Setting Veterans Health Administration. Participants 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). Main outcome measures A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient’s death. Results 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n = 799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. Conclusions Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient’s perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.

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Section: Discussionsupporting

confidence: 84%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation

Oliva

Bowe

Manhapra

et al. 2020

BMJ

171

164

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show abstract

“…[ [73][74][75][76][77][78]. Enacted stigma has also been directly associated with nonfatal overdose [79].…”

Section: The Us Opioid Overdose Crisis Response: Multiple Levels Of Pmentioning

confidence: 99%

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

et al. 2019

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• The current United States opioid overdose crisis is a complex, multifaceted, public health emergency that urgently requires the implementation of evidence-based primary, secondary, and tertiary preventive interventions. We develop a typology of the stigma related to opioid use, showing how multiple dimensions of stigma continue to fundamentally hinder the response to the crisis. • Public stigma is driven by stereotypes about people with opioid use disorders, such as their perceived dangerousness or perceived moral failings, which translate into negative attitudes toward people with opioid use disorders. • Enacted stigma describes the behavioral manifestations of public stigma, including discrimination and social distancing. Public and enacted stigma, in turn, lead to delivery of suboptimal care and undermine access to treatment and harm reduction services. • Public stigma and enacted stigma can become structural stigma when they become encoded in cultural norms, laws, and institutional policies. Collectively, these forms of stigma run at cross purposes to-and reduce public support for-public health-oriented policies to address the opioid overdose crisis.

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“…Regardless of whether opioids are effective for chronic pain-often they are not-patients receiving long-term opioids cannot simply discontinue opioids. 8,9 It is easy to envision scenarios in which misapplication of the 5-day law could cause interruptions in long-term opioid therapy. Such interruptions may harm patients by, for example, inducing acute opioid withdrawal symptoms (including severe pain and psychological distress), disrupting patient-physician relationships, or prompting patients to seek opioids from nonmedical sources.…”

mentioning

confidence: 99%

Evaluating Consequences of Opioid Prescribing Policies

Krebs

2020

J GEN INTERN MED

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Opioid medication discontinuation and risk of adverse opioid-related health care events

Cited by 144 publications

References 13 publications

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

Evaluating Consequences of Opioid Prescribing Policies

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