Study: Tapering Opioid Prescriptions May Increase Risk of Overdose

With opioid-related deaths continuing to rise, especially due to COVID-19 pandemic, physicians are looking for alternatives to the drugs, while reducing doses for patients already on prescriptions.

But, a new study suggests that this reduction in dosing—called tapering—may actually increase the likelihood that a patient will overdose or struggle with a mental health crisis.

Using data from administrative claims, lead study author Alicia Agnoli, MD, MPH, MHS, assistant professor in the department of family and community medicine at UC Davis School of Medicine, looked at the medical and pharmacy claims for over 100,000 patients from 2007 to 2019. 

Only participants who were prescribed stable high opioid doses (at least 50 morphine milligrams per day) for over a year were included in the study. Researchers specifically looked to see if participants were admitted to emergency rooms for:

• Drug overdoses
• Alcohol intoxication
• Drug withdrawal
• Depression
• Anxiety
• Suicide attempts

The researchers then compared these outcomes for patients after tapering their doses to those for people before or without tapering.

Agnoli and her team found that the risk of overdose and mental health crises was higher in patients whose opioid doses were reduced more rapidly.

There was a 68% increase in overdose events for people who tapered off opioids compared to non-tapered patients. They also experienced double the number of mental health crises. The risks of tapering were greater in people whose doses were reduced faster and who initially were prescribed higher baseline doses.

“That suggests that those populations need even more support if they are going to be undergoing any kind of dose reduction,” Agnoli tells Verywell. The August study was published in JAMA.

The Risks of Opioid Tapering

According to study co-author Joshua J. Fenton, MD, MPH, professor in the department of family and community medicine at UC Davis, the Centers for Disease Control and Prevention (CDC) issued an opioid prescribing guideline in 2016.

These guidelines stated that "clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety."

“And what we found was that there was a pretty sharp increase in the rate of tapering after the guideline came out in 2016,” Fenton tells Verywell. “It became very common for patients to have their doses reduced, especially patients prescribed a higher baseline dose.” 

But opioids' addictive properties make tapering particularly risky.

“They [opioids] are medicines that carry with them an intrinsic risk to the patient who is prescribed them," Agnoli says. "On a population level, these medicines are highly addictive, and they have quite a lot of demand." She adds that among the non-prescribed community, opioids can be misused. 

“Patients who have been on a previously stable, long-term dose of opioid therapy, do develop physiologic dependence on it,” Agnoli explains. “Decreasing that dose or discontinuing that dose can be somewhat destabilizing.” 

According to the U.S. Department of Health and Human Services (HHS), risks for rapid opioid tapering include:

• Significant opioid withdrawal
• Exacerbation of pain
• Serious psychological distress
• Suicidal ideation
• Seeking illicit opioids to treat their pain or withdrawal symptoms 

Because of the risks, the department does not recommend abrupt opioid reduction or discontinuation.

Tapering Needs to Be Slow

While tapering is an option, Agnoli says it should be entered into carefully between a patient and their prescriber when there’s an agreement that continuing therapy carries greater risk. 

“A patient is to begin to taper, our findings suggest very slowly, with a lot of close and psychological support, patient, and regular check-ins to ensure that the patient is not having any early signs of these downstream terrible consequences,” Agnoli says. 

The HHS recommends considering opioid dosage tapering based on the below reasons and a few other instances:

• The pain improves
• A patient receives a treatment that is expected to improve pain
• The patient requests a dosage reduction or discontinuation 
• Pain and function are not meaningfully improved
• The patient has evidence of opioid misuse 
• The patient experiences side effects that diminish quality of life or impair function
• The patient is takes medications (e.g., benzodiazepines) or has medical diagnosis, including lung disease, sleep apnea, liver disease, kidney disease, fall risk, and advanced age, which increase risk for adverse outcomes

While the study hones in on the need for more carefully guided and supportive opioid tapering, Agnoli also stresses the need for evidence-based strategies. 

“We need more attention on the evidence-based strategies that we know prevent opioid overdose, like access to Naloxone, and access to medications for opioid use disorder,” Agnoli says.