Abrupt Cessation of Long-Term Opioid Prescribing Common Save

Medicare beneficiaries were increasingly likely to have long-term opioid therapy stopped in recent years and medication changes often were abrupt, not tapered, an observational study showed.

Long-term opioid discontinuations among Medicare Part D beneficiaries increased by 49% from 2012 to 2017 and most were rapid, "falling off a cliff" drug changes, reported Michael Barnett, MD, MS, of Harvard T. H. Chan School of Public Health and Brigham and Women's Hospital in Boston, and co-authors.

The proportion of abrupt opioid discontinuations increased over time, from 70.1% in 2012 to 81.2% in 2017 (P<0.001), they wrote in the Journal of General Internal Medicine.

Patients on long-term opioid therapy "face significant stigma and misunderstanding in the current healthcare system," Barnett said. "There are many reports of patients being indiscriminately discontinued from their medications, but little data to investigate these concerning reports," he told MedPage Today.

"The vast majority of long-term opioid users whose therapy was discontinued had an extremely rapid, abrupt taper that was far outside of guideline recommendations," Barnett added. "It would have been concerning to find that, say, one in four long-term opioid users had abrupt cessation of their therapy but we found that it was most, even among those with very high daily doses of opioids."

The CDC and FDA have published cautions against abrupt tapering, citing it as dangerous to patient health, noted Beth Darnall, PhD, director of the Stanford University Pain Relief Innovations Lab, who wasn't involved with the research.

This study highlights the pervasiveness of poor tapering practices occurring from 2012-2017 and the extent of pain care disparities, she observed. "As of 2017, these alarming trends continued to increase," Darnall told MedPage Today. "There is a desperate need for improved healthcare and safety measures for people with chronic pain taking prescribed opioids so they are not subjected to unethical and dangerous practices."

The CDC's 2016 guideline for chronic pain opioid prescribing prompted a big focus to reduce overprescribing. Some state agencies and insurance companies used the guideline to push hard dose limits and abrupt tapering, which the CDC later said was inconsistent with its recommendations.

"In 2018, a group of us authored a letter to HHS calling for urgent action against forced and abrupt opioid tapering," Darnall said. "In 2019, HHS issued guidance for patient-centered opioid tapering that promotes consensual tapering practices."

In their study, Barnett and co-authors looked at claims for a 20% sample of Medicare beneficiaries on long-term opioid therapy for at least 1 year, defined as four or more consecutive quarters with more than 60 days of opioids supplied in each quarter from January 2011 through December 2017. People with a cancer diagnosis besides skin cancer and hospice patients were excluded, as were people on an average daily dose of 25 morphine milligram equivalents (MME) or less during their initial 12-month long-term opioid therapy period.

Most (70.3%) long-term opioid users in the study were eligible for Medicare due to disability. Mean age was 60 and 58% were women.

Long-term opioid discontinuation was defined as at least 60 consecutive days without opioids supplied. The researchers evaluated whether discontinuation was tapered or abrupt by comparing patients' daily MME dose in the last month of therapy to their average daily dose in a baseline period of 7 to 12 months before discontinuation. By the last month of therapy, patients with abrupt discontinuation had at least a 50% reduction in their baseline average daily dose.

The study identified 258,988 long-term opioid therapy users; of these, 17,617 (6.8%) discontinued therapy. Adjusted rates of discontinuation increased from 5.7% of users in 2012 to 8.5% in 2017. Increases in annual discontinuation rates were similar for people on lower (26-90 MME, 5.8% to 8.7%) and higher (more than 90 MME, 5.3% to 7.7%) doses.

People eligible for Medicare because of disability had a greater increase in the probability of discontinuing opioids from 2012-2017 (adjusted rates 5.9% to 9.2%, 56% relative increase) compared with people not eligible due to disability (5.2% to 7.0%, 35% relative increase, P<0.001 for interaction).

While it was common for patients on lower daily MME doses to have long-term opioids stopped rapidly, the majority of patients on very high doses -- even over 200 MME -- who stopped also had an abrupt discontinuation, Barnett and co-authors reported.

"We need more education and support for patients on long-term opioid therapy to taper in a clinically rational way and maintain excellent continuity of care with their pain management team," Barnett said.

The study had several limitations, the researchers noted. Data represent Medicare beneficiaries only, predominantly the disabled Medicare population, and may not apply to other people. The intended tapering strategy for these patients wasn't known and it's possible the data reflect a bias toward abrupt discontinuation.

Judy George covers neurology and neuroscience news for MedPage Today, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more. Follow 

Source Reference: Neprash HT, et al "Abrupt discontinuation of long-term opioid therapy among Medicare beneficiaries, 2012-2017" J Gen Intern Med 2021; DOI: 10.1007/s11606-020-06402-z.