Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017
Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017
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DOI：
10.1001/jamanetworkopen.2019.16271
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发表时间：
2019-11-01
影响因子：
13.8
通讯作者：
Magnan, Elizabeth
中科院分区：
文献类型：
--
作者：
Fenton, Joshua J.;Agnoli, Alicia L.;Magnan, Elizabeth
2016年疾病控制和预防中心的处方指南警告不要使用高剂量的长期阿片类药物治疗，并建议如果风险超过收益，则每周将每日阿片类药物剂量减少约10%。为了描述2008年至2017年长期阿片类药物处方患者中阿片类药物剂量逐渐减少的美国趋势，并确定与逐渐减少和更快的逐渐减少率相关的患者水平变量。这项回顾性队列研究使用了100031名商业保险和医疗保险优势登记者的去识别医疗和药房索赔和登记记录，代表了美国各地年龄、种族/民族和地理区域的多样化混合。成年人稳定，高剂量（平均值，>= 50吗啡毫克当量[MME]/d）阿片类药物处方，12个月基线期和2008年1月1日至2017年12月31日的2个月或更长时间随访，主要结果和指标：逐渐变细定义为15%在7个月随访期内的6个重叠60天窗口期内，平均每日MME相对降低或更多。减量率计算为每月最大剂量减少百分比。（53 452名[53.4%]妇女;平均[SD]年龄，57.6 [11.8]岁），2008年至2015年，逐渐减少每日阿片类药物剂量的患者的年龄和性别标准化百分比从10.5%增加到13.7%（调整后的年发病率比[aIRR]，1.05 [95% CI，1.05-1.06]），2016年增至16.2%，2017年增至22.4%（2016-2017年与2008 - 2015年的aIRR，1.20 [95% CI，1.16-1.25]）。与减量相关的患者水平协变量包括女性（aIRR，1.13 [95% CI，1.10-1.15]）和较高的基线剂量（aIRR>= 300 MME/d vs 50-89 MME/d，2.57 [95% CI，2.48-2.65]）。在逐渐减少阿片类药物每日剂量的患者中，平均（SD）最大剂量减少为每月27.6%（17.0%），18.8%的患者的最大减量率超过每月40%（即，每周快于10%）。与2008-2015年相比，2016-2017年的剂量降低速度更快（校正差异，1.4%[95% CI，0.8%-2.1%]）和较高基线剂量（调整后的差异，2.7%[95% CI，结论和相关性使用长期阿片类药物治疗的患者越来越多地经历剂量递减，特别是女性和那些处方较高剂量的患者;此外，自2016年以来，剂量逐渐减少变得更加普遍。许多正在逐渐减少的患者以快速的最大速率减少每日剂量。
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 100 031 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 100 031 participants (53 452 [53.4%] women; mean [SD] age, 57.6 [11.8] years), from 2008 to 2015, the age- and sex-standardized percentage of patients tapering daily opioid doses increased from 10.5% to 13.7%(adjusted incidence rate ratio [aIRR] per year, 1.05 [95% CI, 1.05-1.06]) before increasing to 16.2% in 2016 and 22.4% in 2017 (aIRR in 2016-2017 vs 20082015, 1.20 [95% CI, 1.16-1.25]). Patient-level covariates associated with tapering included female sex (aIRR, 1.13 [95% CI, 1.10-1.15]) and higher baseline dose (aIRR for >= 300 MMEs/d vs 50-89 MMEs/d, 2.57 [95% CI, 2.48-2.65]). Among patients tapering daily opioid doses, the mean (SD) maximum dose reduction was 27.6%(17.0%) per month, and 18.8% of patients had a maximum tapering rate exceeding 40% per month (ie, faster than 10% per week). More rapid dose reduction was associated with 2016-2017 vs 2008-2015 (adjusted difference, 1.4%[95% CI, 0.8%-2.1%]) and higher baseline dose (adjusted difference, 2.7%[95% CI, 2.2%-3.3%] for 90-149 vs 50-89 MMEs/d).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.