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Saturday, December 3, 2022

UC Davis Health study finds that long-term risks are associated with opioid dose reduction

Increased rates of overdose and mental health crises spur closer monitoring of patients undergoing opioid tapering

 

By BRANDON NGUYEN — science@theaggie.org

 

The opioid epidemic or crisis began in the 1990s when pharmaceutical companies marketed opioids as non-addictive and encouraged physicians and clinicians to prescribe the medication at a higher rate for patients with acute or chronic pain. However, this led to widespread misuse of prescription and non-prescription opioids as they led to addiction among users. 

According to the U.S. Department of Health and Human Services, over 10 million people have misused prescription opioids, not accounting for non-prescribed or illicit use of opioids. In addition, over 70,000 people have died from drug overdose due to the medications’ addictive nature. In response to the crisis, physicians across the country have agreed on efforts to reduce opioid dosages to prevent overdose, also known as “tapering.” 

A recent UC Davis Health study examined the potential long-term risks of opioid dose tapering. The researchers found that patients on stable but higher-dose opioid therapy who had their dosage tapered by at least 15% had significantly higher rates of overdose and mental health crisis in the second year after tapering as compared to their pre-tapering period.

Dr. Joshua Fenton, a professor and vice chair of research in the Department of Family and Community Medicine at the UC Davis School of Medicine and the lead author of the study, provided context around the efforts to taper opioid doses.

“It’s become increasingly clear that prescription opioids are connected to this larger problem of increased overdose rates annually,” Fenton said. “Over the past 10 years, there have been a lot of policy changes and regulatory changes that have come out from the CDC, for example, and tried to put the brakes on this. And sometimes, this has been done very rapidly, where doctors have taken patients who are on very high doses to much lower doses over short periods of time.”

This dramatic shift in dosage, Fenton explained, led to concerns of overdose and mental health crisis yet again, despite reducing the strength of the medication. 

“There’s been a lot of concern about the safety of that practice [of tapering] and the potential adverse effects of that practice,” Fenton said. “Some of our workers have really suggested that that’s a significant problem.”

For Dr. Elizabeth Magnan, a physician in the Department of Family and Community Medicine at the UC Davis School of Medicine and collaborator on the study, the crisis is much more complex than simply resolving it with tapering.

“The idea behind tapering was that we thought it would be safer for people, and we thought that perhaps people might even have better control in some cases, but newer research and anecdotal reports have shown that this might not always be the case and that there are risks with tapering,” Magnan said. “The crisis is very complicated, and I think that it has to be taken at an individual level between the clinician and patient, guided by some national guidelines and ideas, but not have a one size fits all or really strict guideline for how we manage people and their pain.”

Daniel Tancredi, a professor of pediatrics at UC Davis Health and co-author of the study, helped with the study’s design, which collected data from a database of more than 28,000 patients who had been prescribed long-term opioids over a 10-year period. 

“We used an innovative observational study design to understand the patients’ experience before and after opioid-dose reduction,” Tancredi said. “We compared outcome rates in pre- and post-taper periods with patients serving as their own controls. This design has the advantage of controlling for patient characteristics that may influence relationships between tapering and adverse events.”

According to the study, results revealed that for every 100 patients, there was an average of 3.5 overdose or withdrawal events and 3 mental health crises during the pre-tapering period, compared to 5.4 events and 4.4 crises in the second year of the post-tapering period. That is a 57% increase in overdose or withdrawal incidents and a 52% increase in mental health crises.

To account for the risks of overdose and mental health crises in the process of tapering, Fenton emphasized the need for doctors to closely observe and check in with patients prescribed opioids in efforts to end the opioid epidemic.

“The Department of Health and Human Services has made some recommendations to make the tapering process more bearable and successful for patients,” Fenton said. “Managing patients who are undergoing tapering and monitoring them is part of that, and we definitely think the patient should be seen regularly as they should be very carefully assessed for substance misuse, as well as how they’re tolerating the taper and their pain level and how they’re coping from a mental health standpoint. Problems with depression and suicidal ideation, for example, need to be kind of carefully monitored and addressed as they arise.”

 

Written by: Brandon Nguyen — science@theaggie.org