Associations between tapering or discontinuing opioids and subsequent pain-related primary care visits

Context: Tapering and discontinuation of chronic opioids has increased, with subsequent reports of exacerbated pain and increased emergency department (ED) visits associated with tapering.

Objective: To evaluate the associations between opioid dose tapers with continued opioid use and opioid tapers with discontinuation, and subsequent pain-related utilization primary care visits, ED encounters, and hospitalizations.

Study Design: Retrospective cohort study.

Dataset: Administrative data from the Optum Labs Data Warehouse 2015-2019 that contains de-identified medical and pharmacy claims and eligibility information for commercial and Medicare Advantage enrollees in the US.

Population: Adults who were prescribed stable opioid doses (≥50 morphine milligram equivalents [MME]/day) over a 12-month baseline period

Outcome Measures: Total monthly primary care visits, ED visits, and hospitalizations for pain-related diagnoses, including musculoskeletal or other specific chronic conditions (but excluding acute, emergent conditions) for up to 12 months.

Analysis: Monthly visit counts were modeled using negative binomial regression as a function of tapering (≥15% relative dose reduction from baseline), compared to non-tapered reference group, subclassified as tapered-and-continued (MME>0) vs. tapered-and-discontinued (MME=0), baseline utilization, sociodemographics, and comorbidities.

Results: Among 47,033 patients prescribed stable opioids, 13,793 (29.3%) tapered after cohort entry; of these, 10,579 (76.7%) tapered-and-continued and 3,214 (23.3%) tapered-and-discontinued. Compared to non-tapered, patients who tapered-and-discontinued had fewer primary care visits for pain (adjusted incidence rate ratio [aIRR] 0.68, 95% CI: 0.61-0.76) and similar rates of pain-related ED visits (aIRR 1.12, 95% CI: 0.95-1.31) and hospitalizations (aIRR 0.74, 95% CI: 0.54-1.02). Relative to non-tapered patients, patients who tapered-and-continued was had similar rates of pain-related primary care visits (aIRR 1.01, 95% CI: 0.97-1.06) but significantly more pain-related ED visits (aIRR 1.23, 95% CI: 1.14-1.32) and hospitalizations (aIRR 1.14, 95% CI: 1.03-1.27).

Conclusions: Results suggest that opioid tapers resulting in discontinuation may lead to decreased pain-related primary care utilization, whereas tapering with continuation may precipitate an increase in pain-related ED and hospital use.