Stigma and safety fears have made daily dose tapering of opioid prescriptions more common. New research from UC Davis Health physicians, however, shows tapering can occur at rates as much as six times higher than recommended, putting patients at risk of withdrawal, uncontrolled pain or mental health crises.
The study -- "Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017" -- is published in JAMA Network Open. The results also will be presented at the Nov. 16-19 North American Primary Care Research Group meeting in Toronto.
"Tapering plans should be based on the needs and histories of each patient and adjusted as needed to avoid adverse outcomes," said study author Alicia Agnoli, assistant professor of family and community medicine. "Unfortunately, a lot of tapering occurs due to policy pressures and a rush to get doses below a specific and sometimes arbitrary threshold. That approach can be detrimental in the long run."
In 2016, the U.S. Centers for Disease Control and Prevention (CDC) recommended dose tapering, or a slow reduction in prescription opioid doses over time, if the risks of continuing opioids outweigh the benefits. That point in time is usually when a patient is taking 90 morphine milligram equivalents -- or MMEs -- each day, and that dose is no longer reducing pain or improving daily functions. The CDC advises a slow decrease of 10% MMEs per month.
The study team set out to examine trends in opioid dose tapering and if tapering rates were consistent with CDC recommendations.
"We wanted to understand how often opioid dose tapering happens, how rapidly patients' doses were being reduced when tapering, and which patients were more likely to have doses tapered," said lead author Joshua Fenton, professor of family and community medicine.
Tapering faster than recommended
Fenton and Agnoli evaluated medical and pharmacy claims and enrollment records for more than 100,000 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities and locations across the U.S. They focused on individuals whose opioid doses were stable for at least a year and identified tapering patients as those with a 15% or more reduction in daily MMEs during a seven-month follow-up period.
They found that dose tapering became more common throughout the study period of 2008-2017, with the biggest jump following the CDC's 2016 prescribing guidelines. Tapering increased from 10.5% to 13.7% from 2008 to 2015, and from 16.2% to 22.4% from 2016 to 2017. Tapering was much more common in patients prescribed higher opioid dosages.
They also found that the rate of dose reduction often was well beyond the CDC's recommendation of 10% per month. The average reduction overall was 27.6% per month. Nearly 20% of patients tapered at a rate of 40% per month, and 5% tapered at a rate faster than 60% per month.
The 2016 policy could have been misinterpreted, leading many prescribers and health systems to insist on faster-than-recommended tapering, according to Agnoli.
"There is definitely a lot of pressure to reduce opioid use among patients, but there also is a need for more training and guidance for prescribers on how to help them safely do so," Agnoli said.
Women and tapering
Fenton and Agnoli also identified patient variables associated with tapering and uncovered an interesting difference in tapering rates based on sex.
While men have much higher rates of opioid use disorder and adverse outcomes related to opioids, women were more likely than men to have their opioid doses tapered.
"We think this has a lot to do with the gender dynamics of pain management and the physician-patient relationship," Agnoli said. "How women experience pain and discuss pain with their physicians is perhaps very different than men. There also could be some sex bias in terms of the patients that physicians choose to initiate conversations with about dose reduction."
Minimizing tapering risks
The researchers hope to build on this work to inform best practices for safe decision-making around dose reduction for all patients prescribed opioids.
"Ultimately, we want to clarify the effects of tapering on patients and how to help them taper to maximize benefits and minimize risks," Fenton said. "We expect this line of research will have important implications for how physicians manage and monitor patients who are undergoing opioid tapering."
Collaborators on this research were Guibo Xing, Daniel Tancredi, Anthony Jerant and Elizabeth Magnan of UC Davis Health, and Lillian Hang and Aylin Altan of OptumLabs in Minneapolis.
Their study was supported by UC Davis Health and OptumLabs and is available online.
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