Opioid tapering raises the risk of overdose and mental health crisis in patients who have taken opioids long term. A new study found tapering raised overdose risk 1.68 times and mental health crisis risk 2.28 times. Vague guidelines leave room for tapers that move too fast.
Summary: Many people are prescribed opioids for moderate to severe pain. Often they get a high dose for a long time. Doctors often try to taper (slowly lower) the dose to cut the health risks of high doses. There are guidelines on tapering. But they also say the final call belongs to the doctor. Because the rules are vague, some prescribers taper too hard. The new study shows that even a slight taper can cause severe harm in people on opioids for a long time. Tapering seems to raise the risk of drug overdose by 1.68 times. It seems to raise the risk of a mental health crisis by 2.28 times.
Opioids treat moderate to severe pain. They are often prescribed for a long time in conditions like cancer. But doctors also prescribe them for less severe problems, like chronic lower back pain. Long-term use brings problems. Studies show at least one-fourth of patients become addicted to these drugs1. That shows the need for opioid addiction treatment.
So for many people, stopping these drugs all at once is not an option. That is why the US FDA changed its advice in 2019. It said sudden opioid stopping should be avoided. That is because a sudden stop causes uncontrolled pain and mental health problems2.
Since a sudden stop is off the table, the US FDA advises a slow taper of the dose. But this puts doctors in a tough spot. The US FDA clearly states that no single tapering plan fits all patients. So every taper has to be built around the patient’s health. The US FDA also states that tapering may cause severe withdrawal symptoms in some2.
With no clear guidelines, doctors face a hard choice. They need to get some patients off opioids. But even a slight taper may cause severe withdrawal in some people. A new study in the journal JAMA shows this3.
The JAMA study looked at data from 113,618 patients who took high-dose opioids long term. It compared rates of overdose and mental health crisis in two ways. It looked at patients who were not tapered. It also looked at patients before their taper began. The study found tapering raised the risk of overdose by 1.68 times. It raised the risk of a mental health crisis by 2.28 times.
This study matters for a few reasons. First, it is very large. Second, the statistical gap between the two groups is huge. So there is no doubt: any taper after long-term opioid use is tied to real health risks.
Some experts think opioid addiction alone cannot explain these problems. Often the cause may be a severe, painful disease that other drugs cannot control. After all, opioids are often a last resort. For these people, stopping opioids is not an option.
People who took fairly high doses for a long time will always face a higher risk of overdose or mental health crisis. Again, that is simply because these people live with many severe conditions.
There are guidelines on opioid tapering. But those guidelines also say the doctor should decide based on the patient’s health. Recent surveys show that in many cases, doctors may be tapering too hard and too early4.
The new survey shows that after the CDC 2016 guidelines, doctors began tapering opioids in most cases. Doses were cut in 55.6% of cases. And 24.87% were taken off opioids completely. About 60% of patients say they were tapered or taken off against their wishes. In 2022, the CDC Clinical Practice Guideline for Prescribing Opioids for Pain replaced the 2016 guideline. It removed the hard dose limits that had been used as rules.
To sum up, long-term opioids are mostly prescribed for severe pain that is hard to treat. But many of these patients also become addicted. Tapering is one way to lower opioid-related health risks. But tapering too hard can backfire. It may raise the risk of drug overdose and mental health crises.
Frequently asked questions
Does tapering opioids raise the risk of overdose?
Yes. A study in JAMA followed 113,618 patients who took high-dose opioids for a long time. After tapering, their risk of overdose rose 1.68 times. Their risk of a mental health crisis rose 2.28 times. Even a slight taper harmed some patients. So how fast the dose comes down matters as much as the choice to lower it.
What is a typical tapering schedule for opioids?
There isn’t one. The US FDA states that no single tapering plan is right for every patient. The dose has to come down based on each person’s health. The guidelines leave the final call to the doctor. That vague wording is why some prescribers taper too hard and too early.
Does tapering make withdrawal easier?
Tapering is safer than stopping cold. In 2019, the FDA changed its advice. It said sudden opioid stopping should be avoided, because it causes uncontrolled pain and mental health problems. A slow taper is the advised route. But the FDA also warns that even a slow taper can trigger severe withdrawal in some people.
How did the CDC guideline change opioid tapering?
After the CDC’s 2016 guideline, doctors began tapering opioids in most cases. Doses were cut in 55.6% of cases. And 24.87% of patients were taken off opioids completely. About 60% of patients said it happened against their wishes. In 2022, a new CDC guideline replaced the 2016 one. It removed the hard dose limits that had been used as rules.
Related reading
Opioid Dose Falls When Pain Is Treated, Not Tapered · ER-Prescribed Opioids Unlikely to Cause Addiction · OPAL Study on Opioids for Back and Neck Pain Questioned
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
Sources
- Agnoli A, Xing G, Tancredi DJ, et al. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021;326(5):411-419. PMID 34342618 · DOI 10.1001/jama.2021.11013.
- Fenton JJ, Magnan E, Tseregounis IE, et al. Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering. JAMA Netw Open. 2022;5(6):e2216726. PMID 35696163 · DOI 10.1001/jamanetworkopen.2022.16726.