Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017

Importance A 2016 Centers for Disease Control and Prevention prescribing guideline cautioned against higher-dose long-term opioid therapy and recommended tapering daily opioid doses by approximately 10% per week if the risks outweigh the benefits. Warnings have since appeared regarding potential hazards of rapid opioid tapering. Objectives To characterize US trends in opioid dose tapering among patients prescribed long-term opioids from 2008 to 2017 and identify patient-level variables associated with tapering and a more rapid rate of tapering. Design, Setting, and Participants This retrospective cohort study used deidentified medical and pharmacy claims and enrollment records for 99 874 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races/ethnicities, and geographical regions across the United States. Adults with stable, higher-dosage (mean, ≥50 morphine milligram equivalents [MMEs]/d) opioid prescriptions for a 12-month baseline period and 2 or more months of follow-up from January 1, 2008, to December 31, 2017, were included in the study. Main Outcomes and Measures Tapering was defined as 15% or more relative reduction in mean daily MME during any of 6 overlapping 60-day windows within a 7-month follow-up period. The rate of tapering was computed as the maximum monthly percentage dose reduction. Results Among the 99 874 participants (53 358 [53.4%] women; mean [SD] age, 57.4 [11.8] years), from 2008 to 2015, the age- and sex-standardized percentage of patients tapering daily opioid doses increased from 12.7% to 16.2% (adjusted incidence rate ratio [aIRR] per year, 1.05 [95% CI, 1.05-1.06]) before increasing to 18.6% in 2016 and 23.1% in 2017 (aIRR in 2016-2017 vs 2008-2015, 1.16 [95% CI, 1.12-1.20]). Patient-level covariates associated with tapering included female sex (aIRR, 1.09 [95% CI, 1.07-1.11]) and higher baseline dose (aIRR for ≥300 MMEs/d vs 50-89 MMEs/d, 2.19 [95% CI, 2.12-2.27]). Among patients tapering daily opioid doses, the mean (SD) maximum dose reduction was 34.0% (27.4%) per month, and 26.5% of patients had a maximum tapering rate exceeding 40% per month (ie, faster than 10% per week). Higher maximum dose reduction rate was associated with age 18 to 34 years (vs older age groups), male sex, a high school education or less (vs more education), small town or rural residence (vs metropolitan, micropolitan, or unknown), a Charlson Comorbidity Index score of 3 or higher (vs 0) (adjusted difference, 1.9% [95% CI, 0.9%-2.9%]), lower baseline doses (50-89 MMEs vs 150-299 or ≥300 MMEs), and a recent drug overdose (adjusted difference, 10.2% [95% CI, 6.8%-13.6%]). Conclusions and Relevance Patients using long-term opioid therapy are increasingly undergoing dose tapering, particularly women and those prescribed higher doses; in addition, dose tapering has become more common since 2016. Many patients undergoing tapering reduce daily doses at a rapid maximum rate.