Summary: Large number of people are prescribed opioids for moderate to severe pain. In many cases, opioids are prescribed at a higher dosage for a prolonged interval. Quite often, doctors would try to taper the opioid dose to reduce health risks associated with high opioid dosage. Although there are guidelines regarding tapering, but they also say that final decision should be made by the doctor. This ambiguity in guidelines mean that some prescribers try to taper opioid dose too aggressively. The new study shows that even slight tapering in patient on opioids for a long time may cause severe harms. It appears that tapering increases the risk of drug overdose by 1.68 times and the risk of mental health crisis by 2.28 times.
Opioids are used to treat moderate to severe pains. Quite often, they are prescribed for a prolonged period in conditions like cancer. However, doctors also prescribe them in less severe conditions like chronic lower back pain. However, there are some issues regarding their prolonged use. Studies show that at least one-fourth of patients become addicted to these medications1, underlining the need for opioid addiction treatment.
It means that sudden withdrawal of these medications is not an option in many. Thus, US FDA revised its recommendations in 2019, suggesting that sudden opioid discontinuation should be avoided. It is because a sudden withdrawal causes uncontrolled pain and mental health issues2.
Since a sudden opioid withdrawal is not an option, US FDA recommends gradual tapering of the dosage. However, the practitioners are faced with a tough choice here, as the US FDA clearly states that no single tapering plan is good for all patients. It means that any drug tapering should be done by considering the patient’s health condition. New US FDA also states that dose tapering may cause severe withdrawal symptoms in some2.
The absence of any clear guidelines means that doctors are faced with a dilemma. They need to get some patients off the opioids. However, it appears that even slight tapering may cause severe withdrawal symptoms in some, as shown by a new study published in the journal JAMA3.
The study published in the JAMA analyzed the data of 113 618 patients who were prescribed high-dose opioids for the long term. They compared the prevalence of overdose and mental health crisis in patients without tapering or prevalence of these conditions before tapering. The study found that tapering increased the risk of overdose by 1.68 times and that of mental health crisis by 2.28 times.
This study is relevant in many ways. Firstly, it has a large sample size. Secondly, there is a huge statistical difference between the two groups. Thus, there is no doubt that any tapering after prolonged opioid use is associated with considerable health risks.
Some experts think that these issues cannot be solely explained based on opioid addiction. In many cases, the reason could be a severe and painful disease condition that is difficult to control with other drugs. After all, opioids are often prescribed as a last resort in many cases. It means that discontinuation or withdrawal of opioids is not an option in such cases.
The risk of drug overdose or mental health crisis will always be higher among those who were relatively on high-dose opioids for a long time. But, again, it is simply because these are the people living with multiple severe conditions.
Although there are guidelines regarding opioid tapering, those guidelines also say that a doctor should decide based on a patient’s health condition. However, recent surveys show that in many cases, practitioners might be tapering too aggressively and too early4.
The new survey shows that after CDC 2016 guidelines regarding tapering, doctors started tapering opioids in most cases. As a result, there was a dose reduction in 55.6% of the cases, and 24.87% were taken entirely off the opioids. However, about 60% of patients report that they were taken off or tapered against their wishes.
To conclude, long-term opioids are generally prescribed for severe and difficult to treat pains. However, a large number of these patients also get addicted to these drugs. Although, tapering is one of the ways to lower opioids related health risks. However, aggressive tapering might be counterproductive as it may increase the risk of drug overdose and mental health crises.
References
1. Prescription Opioids | CDC’s Response to the Opioid Overdose Epidemic | CDC. Published October 2, 2021. Accessed November 10, 2021. https://www.cdc.gov/opioids/basics/prescribed.html
2. Research C for DE and. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. FDA. Published online December 20, 2019. Accessed November 10, 2021. https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes
3. Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021;326(5):411-419. doi:10.1001/jama.2021.11013
4. 2021 CDC Survey. Pain News Network. Accessed November 10, 2021. https://www.painnewsnetwork.org/2021-cdc-survey
