Suicide risk after abrupt discontinuation of long-term opioid therapy: an observational cohort study

Centers for Disease Control and Prevention guidelines highlight the increased suicide risk associated with abrupt discontinuations of long-term opioid therapy (LTOT). However, evidence on specific dose and duration "thresholds" of LTOT for suicide risk is limited.

We aimed to identify opioid dose trajectories before abrupt LTOT discontinuations and their association with 6-month suicide risk.

This retrospective cohort study analyzed 2016-2021 Florida Medicaid claims for adult non-cancer beneficiaries with abrupt LTOT discontinuation, defined as having a > 15-day gap in opioid supply after ≥90 consecutive days of use. We assessed prescription opioid doses as the mean weekly morphine-milligram equivalent (MME) 6 months preceding the first abrupt LTOT discontinuation. Group-based trajectory modeling identified distinct opioid trajectory patterns, and multivariable Cox proportional hazards models examined associations between trajectory groups and a composite outcome of suicidal ideation, non-fatal suicide attempts, and suicide death 6 months following the abrupt LTOT discontinuation.

Among 15 680 beneficiaries (mean age: 46.2 ± 11.1 years; 60.8% female), 4 trajectory groups based on weekly MMEs: Low (<25: n = 8814, 56.2%), moderate (25-50: n = 4313, 27.5%), high (51-150: n = 1452, 9.3%), and very-high (>150: n = 1101, 7.0%) were identified. Compared with the low-dose group, the very-high dose group had a significantly higher risk of suicide-related outcomes [adjusted hazard ratio (aHR): 2.2, 95% confidence interval (95%CI):1.3-3.6], while the moderate and high dose groups had similar risks (moderate: aHR = 1.3, 95%CI: 0.9-1.8, high: aHR = 0.7, 95%CI: 0.4-1.3).

Among Florida Medicaid beneficiaries with LTOT, very-high opioid doses (>150 weekly MME) in the 6 months preceding an abrupt LTOT discontinuation were associated with an increased risk of suicide-related outcomes.