Safety and Effectiveness of Opioid Tapering among Older Adults

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PROJECT SUMMARY/ABSTRACT The 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain encourages clinicians to work with patients to lower prescribed opioid doses or to discontinue opioid therapy when the benefits of continued opioid therapy do not overweigh harms. From 2012 to 2018, the overall opioid prescribing rate dropped by 37%; meanwhile, prescriptions for high-dose opioids with daily morphine milligram equivalent (MME) 90 or greater declined by 61% from 2011 to 2018. Older adults with chronic pain, who often have declining organ function, multiple comorbidities, and taking multiple medications, have been increasingly targeted for dose tapering to reduce or discontinue opioid therapy. However, despite declining prescriptions for opioids, opioid-related mortality has not shown a parallel decline, and inappropriate dose tapering (i.e., rapid opioid tapering) may have contributed to the lack of reduction in opioid-related mortality. We propose to (1) assess trends in opioid tapering; (2) study the safety of opioid tapering among older patients with CNCP who were receiving LTOT; and (3) evaluate the effect of opioid tapering on patient-reported outcomes (pain, functional limitations, and psychological status) among older CNCP patients on LTOT who received home health care. We will to use the 2012-2018 5% national representative Medicare administrative claims data and the 2012-2018 Medicare Home Health Outcomes and Assessment Information Set (OASIS) data for the proposed study. Specifically, we hypothesize that: (1) patients undergoing rapid opioid dose tapering are more likely to experience opioid-related adverse events; (2) among patients with high opioid prescribing continuity, the association between rapid opioid dose tapering and opioid-related adverse events will be attenuated as compared to those with poor opioid prescribing continuity; and (3) patients undergoing rapid opioid tapering are more likely to experience severe pain, functional limitations, anxiety and depression. Through the three Specific Aims, we are able to evaluate the safety and effectiveness of opioid therapy among older adults through assessing the patterns of opioid dose tapering as well as through assessing the benefits and harms of opioid dose tapering. To investigate the Specific Aims, a series of retrospective cohort and nested case-control studies will be conducted. While opioid tapering shows promise as a method with which to reduce patient risks and help to alleviate part of the opioid crisis, there is no clear evidence regarding the benefits and harms of opioid tapering. This is especially apparent in the older adult population due to their increased risks of adverse events associated with opioid use. The proposed research is significant because it will contribute to our understanding of the safety and effectiveness of opioid tapering in older adults, which would have a significant impact on the national efforts in balancing the benefits and harms of LTOT and reducing prescription opioid use safely.