What are the risks of tapering chronic opioids?

The Centers for Disease Control and Prevention (CDC) recommends tapering chronic opioid doses when patients do not have meaningful pain benefit and/or show signs of a substance use disorder. Despite increased opioid tapering by physicians in the last few years, however, deaths from opioid use continue to escalate. A new study suggests that tapering long-term opioid doses may be contributing to this increased mortality by increasing affected patients' risks for mental health crisis and/or opioid overdose.

This retrospective cohort study of a national database included over 113,000 participants' records from 2008-2019. The study authors defined tapering as a "at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period." Their main outcomes were emergency department and/or hospital visit for drug overdose, drug withdrawal, and/or mental health crisis. Patients with tapered opioid doses were more likely to present with drug overdose or withdrawal in the subsequent 12 months than patients maintained on their chronic opioid regimen (9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years), and patients with tapered opioid doses were also more likely to present with mental health crisis (depression, anxiety, and/or suicide) than patients maintained on their chronic opioid regimen (7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years). The confidence intervals for both absolute risk differences were statistically significant (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6] and adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3], respectively). 

This study's observational design can only determine correlation, not causation, though the authors cite earlier published studies demonstrating the "potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress." They recommend "more gradual dose reductions" (the CDC recommends reducing doses by no more than 10% a month for patients taking chronic opioids) to reduce the risk of adverse events and call for further research to better define optimal patient selection and dose reduction protocols for opioid tapering. A 2020 AFP Curbside Consultation provides an overview of one current tool to manage opioid tapering, the BRAVO (Broaching the subject, Risk-benefit calculation, Addiction, Velocity and validation, Other strategies) protocol. Unfortunately, some patients with chronic opioid use develop opioid use disorder, and these patients require additional treatment beyond tapering off opioids. The AFP By Topic on the Opioid Epidemic - Key Resources provides articles to guide diagnosis and management, including this overview of "Opioid Use Disorder: Medical Treatment Options." 

The COVID-19 pandemic is accelerating opioid-related mortality; as we await further research, tapering chronic opioid doses, when appropriate, remains a useful tool if we proceed slowly and engage in thoughtful patient-centered decision making regarding its potential risks.