The Association between Opioid Discontinuation and Heroin Use: A Nested Case-Control Study

Binswanger, Ingrid A.; Glanz, Jason M.; Faul, Margaret M.; Shoup, Jo Ann; Quintana, LeeAnn M.; Lyden, Jennifer; Xu, Stan; Narwaney, Komal J.

doi:10.1016/j.drugalcdep.2020.108248

Cited by 38 publications

(49 citation statements)

References 25 publications

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“…However, multiple studies have linked prescription opioid discontinuation with adverse patient outcomes, including mortality and heroin use. [28][29][30][31] A study among the entire parent study sample observed associations between opioid discontinuations and dose reductions and non-prescribed opioid analgesic use, 28 which is consistent with our findings that the interventions under study may have increased the use of non-prescribed opioid analgesics. Also, the treated clinic implemented an integrative pain management program to advance the use of multimodal pain treatments in 2016, which was associated with self-reported improvements in pain, social satisfaction, and mental health outcomes among participating patients.…”

Section: Discussionsupporting

confidence: 87%

“…13,18,19 Evidence regarding the effects of opioid prescribing policies is largely limited to opioid prescribing outcomes. [20][21][22][23][24][25][26] However, several studies have linked reduction or discontinuation of prescribed opioids to adverse patient outcomes, including dropping out of care, 27 illicit use of opioids, 28,29 and death by overdose and suicide. 30,31 In light of these risks, critical examination of the effects of specific policies on both opioid prescribing and unintended patient outcomes, such as illicit opioid use, is needed to identify strategies that are both effective and safe.…”

Section: Introductionmentioning

confidence: 99%

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Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic

et al. 2021

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Background After decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing. Objective To evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013–2014. Design Retrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies. Patients 273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017–2018. Interventions Policies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases. Main Measures Opioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview. Key Results The interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: −52.0 MME [95% confidence interval: −109.9, −10.6]; year 2: −106.2 MME [−195.0, −34.6]; year 3: −98.6 MME [−198.7, −23.9]; year 4: −72.6 MME [−160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [−0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year. Conclusions Clinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change.

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Section: Discussionsupporting

confidence: 87%

Section: Introductionmentioning

confidence: 99%

Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic

et al. 2021

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“…The US Food and Drug Administration issued a prescriber warning about potential hazards of rapid dose reduction in patients prescribed long-term opioids. 9 However, studies assessing harms of opioid dose reduction have been limited to smaller samples, 10 veteran populations, 11 or specific regions 12 or have focused on discontinuation and not included sensitive indicators for tapering initiation. 11,13,14 As clinicians and patients face difficult decisions about whether and how to de-prescribe opioids, 15 there is a need to elucidate the potential harms of stopping or decreasing these medications.…”

mentioning

confidence: 99%

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids

Agnoli

Xing

Tancredi

et al. 2021

JAMA

196

179

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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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“…Another study in the Vermont Medicaid program found rapidity of dose reduction was associated with an increased risk of opioid-related adverse events among those who were discontinued from chronic opioid therapy [ 6 ]. A case-control study from a large integrated health care network found a two-fold higher odds of prescription opioid discontinuation among individuals who used heroin relative to non-heroin users [ 7 ].…”

Section: Discussionmentioning

confidence: 99%

“…However, the evidence that interventions and policies to reduce high-risk opioid prescribing are effective at reducing opioid-related overdoses has been mixed [ 4 ]. There are also concerns and growing evidence that rapid prescription opioid tapering or discontinuation may be associated with adverse outcomes such as increased use of illicit opioids, suicide, and other opioid-related harms [ 5 – 7 ].…”

Section: Introductionmentioning

confidence: 99%

Evaluation of a Medicaid performance improvement project to reduce high-dose opioid prescriptions

Hartung

Geddes

Hallvik³

et al. 2022

BMC Health Serv Res

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Background In 2015, Oregon’s Medicaid program implemented a performance improvement project to reduce high-dose opioid prescribing across its 16 coordinated care organizations (CCOs). The objective of this study was to evaluate the effect of that program on prescription opioid use and outcomes. Methods Using Medicaid claims data from 2014 to 2017, we conducted interrupted time-series analyses to examine changes in the prescription opioid use and overdose rates before (July 2014 to June 2015) and after (January 2016 to December 2017) implementation of Oregon’s high-dose policy initiative (July 2015 to December 2015). Prescribing outcomes were: 1) total opioid prescriptions 2) high-dose [> 90 morphine milligram equivalents per day] opioid prescriptions, and 3) proportion of opioid prescriptions that were high-dose. Opioid overdose outcomes included emergency department visits or hospitalizations that involved an opioid-related poisoning (total, heroin-involved, non-heroin involved). Analyses were performed at the state and CCO level. Results There was an immediate reduction in high dose opioid prescriptions after the program was implemented (− 1.55 prescription per 1000 enrollee; 95% CI − 2.26 to − 0.84; p < 0.01). Program implementation was also associated with an immediate drop (− 1.29 percentage points; 95% CI − 1.94 to − 0.64 percentage points; p < 0.01) and trend reduction (− 0.23 percentage point per month; 95% CI − 0.33 to − 0.14 percentage points; p < 0.01) in the monthly proportion of high-dose opioid prescriptions. The trend in total, heroin-involved, and non-heroin overdose rates increased significantly following implementation of the program. Conclusions Although Oregon’s high-dose opioid performance improvement project was associated with declines in high-dose opioid prescriptions, rates of opioid overdose did not decrease. Policy efforts to reduce opioid prescribing risks may not be sufficient to address the growing opioid crisis.

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The Association between Opioid Discontinuation and Heroin Use: A Nested Case-Control Study

Cited by 38 publications

References 25 publications

Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic

Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids

Evaluation of a Medicaid performance improvement project to reduce high-dose opioid prescriptions

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