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Patient outcomes following opioid dose reduction among patients with chronic opioid therapy.

ABSTRACT
The net effects of prescribing initiatives that encourage dose reductions are uncertain. We examined whether rapid dose reduction after high dose chronic opioid treatment (COT) associates with suicide, overdose, or other opioid-related adverse events. This retrospective cohort study included Oregon Medicaid recipients with high-dose COT. Claims were linked with prescription data from the Prescription Drug Monitoring Program (PDMP) and death data from vital statistics, 2014 to 2017. Participants were placed into four mutually exclusive dose trajectory groups following the high-dose COT period, and Cox proportional hazard models were used to examine the effect of dose changes on patient outcomes in the following year. Of the 14,596 high-dose COT patients, 4,191 (28.7%) abruptly discontinued opioid prescriptions, 1,648 (11.3%) reduced opioid dose prior to discontinuing, 6,480 (44.4%) had a dose reduction but never discontinued, and 2,277 (15.6%) had a stable or increasing dose. Discontinuation, whether abrupt (adjusted hazard ratio (aHR) 3.63; 95% CI 1.42-9.25) or with dose reduction (aHR 4.47, 95% CI 1.68-11.88) significantly increased risk of suicide compared to those with stable or increasing dose. In contrast, discontinuation or dose reduction reduced the risk of overdose compared to those with a stable or increasing dose (aHR 0.36 - 0.62, 95% CI 0.20 - 0.94). Patients with an abrupt discontinuation were more likely to overdose on heroin (vs. prescription opioids) than patients in other groups (p<0.0001). Our study suggests that patients on COT require careful risk assessment and supportive interventions when considering opioid discontinuation or continuation at a high dose.