Long-Term Opioid Therapy Tapering and Risk of Substance Use Disorder and Overdose: Differences by Opioid Dose and...

Tapering from long-term opioid therapy (LTOT) for chronic pain is increasingly common. However, there is inadequate evidence regarding the possibility of adverse effects, particularly across heterogeneous LTOT courses.

To estimate associations of tapering from various LTOT doses and durations with risk of substance use disorder (SUD) and overdose.

Within-individual cohort study.

US adults tapering from at least 3 months of stable LTOT, obtained from Optum's de-identified Clinformatics® Data Mart Database for 2010-2021.

Dose tapering was defined as 2 consecutive months of ≥ 15% lower dose within 6 months of LTOT baseline without abrupt discontinuation. Outcomes were assessed from emergency department or inpatient events with recorded SUD or overdose diagnoses. We compared risk of SUD/overdose across up to 1 year following tapering onset with risk during stable LTOT using conditional logistic regression with time-varying covariates.

Of 732,038 adults who experienced an LTOT taper, 7.6% had at least 1 SUD/overdose event during LTOT baseline or up to 1 subsequent year. Relative to LTOT baseline, odds of SUD/overdose were comparably greater in the month before taper onset (odds ratio [OR], 1.36; 95% CI, 1.32, 1.40) and the first month of tapering (OR, 1.38; 95% CI, 1.34, 1.43). Odds decreased partially across the subsequent year (e.g., month 12: OR, 1.11; 95% CI, 1.07, 1.15). This pattern was consistently observed across groups defined by baseline LTOT dose and duration, although odds returned to baseline levels within approximately 6 months of taper onset for those tapering from higher dose (≥ 90 MME/day) and/or longer duration (≥ 12 months) LTOT.

This within-individual study found that LTOT recipients who experienced a dose taper had greater risk of SUD or overdose around the onset of the taper. Much of that risk escalation may precede-rather than result from-changes in monthly dose.