Identifying opioid tapering pathways to safely stop use

With more and more Australians receiving prescription opioids to treat chronic pain in the past decade, harms as a result of opioid use have also been rising.

Every day in Australia, almost 150 people are admitted to hospitals as a result of opioid harm, and three people die from drug-induced-death involving opioids.

Tapering has been recommended by the Australian government National Health and Medical Research Council (NHMRC) as a key strategy to reduce the harms caused by opioid use, improve pain management, and safely cease using opioids.

The process involves gradually reducing the dose and frequency of the prescribed opioid until it can be safely ceased altogether.

However, stopping suddenly or reducing the dose too quickly can lead to increased pain and emotional distress that could lead to suicide attempts. In addition, many patients are unsuccessful when they attempt to cease their opioid dependence.

Identifying successful pathways

Monash University researchers, led by doctoral researcher and pharmacist Monica Jung, have identified the characteristics of successful tapering pathways that may help people seeking to cease opioid use, and avoid the risk of opioid-related harms.

“By identifying the characteristics of patients, and trajectories that are associated with taper completion, we hope to help clinicians recognise how to achieve better taper outcomes and identify patients who may need further support,” Jung said.

The researchers examined approximately 700,000 de-identified patient records where patients were prescribed a range of tapering programs between 2015 and 2020. Their analysis included both opioid treatments and non-opioid therapies such as referral to a medical specialist.

“Our studies used healthcare data containing one of the largest primary care cohorts of opioid prescribing in Australia, and are the most detailed analyses of opioid taper that we know of in Australia,” Jung said.

“Opioid taper is a difficult and complex process that requires close engagement with a clinician. Our findings offer important insights to help clinicians successfully support patients through this process.”

Characteristics of successful taper

In addition to the trajectories more likely to lead to a successful taper, the researchers also examined patient characteristics, such as socioeconomic status or having an additional diagnosis of depression or anxiety, to identify who is likely to successfully taper their opioid use, and who might need additional support.

Key themes associated with patients successfully ceasing their opioid use for pain were identified.

The type of opioid used during taper

An unexpected finding, in contrast with the guidelines, was that patients who successfully ceased their opioid use were more likely to be prescribed codeine or short-acting morphine as part of their taper strategy.

Rate of taper

Among those completing taper from medium doses, twice as many patients tapered at a faster rate compared to those who tapered at a gradual rate. This finding was also contrasted with the guidelines, and highlights the need for further research to better understand the complexities of taper strategies.

Socioeconomic status

Patients from a higher socioeconomic background were more likely to cease their opioid use with a gradual taper. According to the researchers, this may be because they can access a specialist who can develop an individualised taper regime.

Groups who need greater support

Importantly, several patient groups were identified as less likely to successfully cease opioid use.

“These groups need further support due to a variety of reasons, and we recommend further research to identify the best approaches to successfully ceasing opioid use and manage chronic pain among these groups,” Jung said.

Patients on a high dose or multiple types of opioids when they start to taper

Prescription of high doses or multiple types of opioids may be an indication that patients have higher pain management requirements. Additional interventions may be needed for pain management in these patients, and to avoid over-reliance on opioids.

People diagnosed with a sleep disorder

Since poor sleep can increase pain and, in turn, pain can interfere with sleep, this group was less likely to completely taper off their opioids and were identified as needing greater support.

People diagnosed with depression and/or anxiety

According to the researchers, previous research has found that a mental health condition combined with opioid dependence is linked with unsuccessful taper attempts, and targeted policy and strategic interventions may be required to better support this group.

People from lower geographically-derived socioeconomic status

People from lower socioeconomic groups may struggle to access the specialist care they need, and are at risk of experiencing “prescribing biases”, which include inadequate treatment for chronic pain, or not being referred to a pain specialist.

Previous studies have also identified links between socioeconomic disadvantage and increased rates of opioid prescribing and overdose, which highlights the need for greater support for patients in this group.

Further research needed to fully inform successful opioid tapering regimes

Contrary to recommendations in current guidelines, non-opioid treatments, including the prescription of a non-steroidal anti-inflammatory drug or referral to medical specialists, were more commonly associated with an unsuccessful taper.

While the reasons for this finding were outside the scope of the research, they highlight the need for further studies to identify which non-opioid therapies are likely to be effective.

“Our study found high rates of strong opioid prescriptions across all trajectory groups, with more than half of the patients prescribed strong opioids,” Jung said. “Prescription of strong opioids was positively associated with non-completed taper groups for both low and high doses.

“That almost two-thirds of people on lower doses of opioids didn’t completely taper either clearly demonstrates that taper may be a challenging process even for patients on lower doses, and especially for those prescribed strong opioids.”

Although further research is needed, these findings offer important guidance for clinicians when supporting patients to reduce their opioid dependence, which may help to achieve better taper outcomes.

Read the papers for an analysis of findings, including recommendations for clinicians:

• Trajectories of prescription opioid tapering in patients with chronic non-cancer pain: a retrospective cohort study, 2015-2020
• Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain