Opioid Dose Trajectories Can Help Inform Opioid Management Decision-Making

Increases and decreases to opioid dosing could put a patient at risk of developing an opioid use disorder (OUD) longer-term, so knowing the risks and benefits could help clinicians inform better opioid management, according to a study published in JAMA Network Open.

While more than 50% of participants continued to have opioid dose stability after a 1-year trajectory period, the decreased dose was still associated with reduced OUD risk. However, the decreasing dose was not associated with a significantly lower risk of mortality or overdose after 1 year.

“Although we cannot be certain what clinical strategies or circumstances led to the observed trajectories, the decreasing trajectory appeared consistent with tapering to a lower dose or discontinuing opioids, the high-dose increasing trajectory appeared consistent with dose escalation, and the stable groups appeared consistent with dose maintenance,” the study authors wrote.

Some clinical strategies practice tapering or discontinuing opioid administration to prevent long-term risks of OUD, overdose, and death. These practices may further improve function and quality of life, according to the investigators.

In the study, researchers used a group-based trajectory modeling (GBTM) over 1 year to evaluate associations between opioid dosing trajectories and patient subpopulation outcomes in 3913 patients, more than half of whom were female.

A second objective and the coprimary endpoints included all-cause mortality, incident OUD, continued opioid therapy, disenrollment from the health plan, and overdose after 1 year by comparing baseline and outcome characteristics.

The results show that decreasing the dose had a negative association with OUD, and decreasing opioids was not associated with all-cause mortality. However, there was an observed association between decreasing dose and health care disenrollment.

When decreasing the dose, researchers said that “clinicians should consider how to mitigate the risk of disenrollment.”

On the other hand, continued therapy with opioids was found to increase the risk of mortality and OUD.

“The positive association between increasing and mortality could be due to unmeasured factors related to the underlying risk of death among people selected for dose increases,” the study authors wrote. They suggest strictly monitoring patients on the increased trajectory for signs of a developing OUD.

Limitations of the study include within-group heterogeneity, which was obscured using the GBTM model. Data could have contained inaccuracies as well, due to the recording method. Additionally, some confounding data were not available, including income and education.

Based on these findings, the researchers suggest that patients and clinicians should proceed with caution before going on a trajectory that increases opioids at high doses. The team suggests that more research could be done on the association between patient outcome and health systems or insurance.

“Our findings suggest that physicians and patients should be informed of the longer-term benefits and risks of opioid dose increases and decreases compared with maintaining dose stability,” the study authors concluded.

Reference

Binswanger, Ingrid, Shetterly, Susan, Xu, Stanley, et al. Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment. October 5, 2022. JAMA Netw Open. 2022;5(10):e2234671. doi:10.1001/jamanetworkopen.2022.34671