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- Title
Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment.
- Authors
Binswanger, Ingrid A.; Shetterly, Susan M.; Xu, Stanley; Narwaney, Komal J.; McClure, David L.; Rinehart, Deborah J.; Nguyen, Anh P.; Glanz, Jason M.
- Abstract
This cohort study evaluates the association between opioid dose trajectory and mortality, opioid use disorder, continued opioid therapy, and health plan disenrollment. Key Points: Question: How are 1-year opioid dosing trajectories associated with mortality, opioid use disorder, continued opioid therapy, and health plan disenrollment after the end of the dosing trajectory? Findings: In this cohort study of 3913 patients, a decreasing opioid dose trajectory was associated with a lower risk of opioid use disorder and continued opioid therapy compared with stable dosing trajectories, but also was associated with an increased risk of disenrollment. Decreasing dose was not associated with mortality in the year after the end of the trajectory period; however, an increasing dose trajectory was associated with an increased risk of mortality and opioid use disorder but had no association with continued opioid therapy or disenrollment. Meaning: These findings suggest clinicians and patients should carefully weigh the long-term risks and benefits of opioid dose increases and decreases compared with maintaining stable opioid dosing. Importance: Uncertainty remains about the longer-term benefits and harms of different opioid management strategies, such as tapering and dose escalation. For instance, opioid tapering could help patients reduce opioid exposure to prevent opioid use disorder, but patients may also seek care elsewhere and engage in nonprescribed opioid use. Objective: To evaluate the association between opioid dose trajectories observed in practice and patient outcomes. Design, Setting, and Participants: This retrospective cohort study was conducted in 3 health systems in Colorado and Wisconsin. The study population included patients receiving long-term opioid therapy between 50 and 200 morphine milligram equivalents between August 1, 2014, and July 31, 2017. Follow-up ended on December 31, 2019. Data were analyzed from January 2020 to August 2022. Exposures: Group-based trajectory modeling identified 5 dosing trajectories over 1 year: 1 decreasing, 1 high-dose increasing, and 3 stable. Main Outcomes and Measures: Primary outcomes assessed after the trajectory period were 1-year all-cause mortality, incident opioid use disorder, continued opioid therapy at 1 year, and health plan disenrollment. Associations were tested using Cox proportional hazards regression and log-binomial models, adjusting for baseline covariates. Results: A total of 3913 patients (mean [SD] age, 59.2 [14.4] years; 2767 White non-Hispanic [70.7%]; 2237 female patients [57.2%]) were included in the study. Compared with stable trajectories, the decreasing dose trajectory was negatively associated with opioid use disorder (adjusted hazard ratio [aHR], 0.40; 95% CI, 0.29-0.55) and continued opioid therapy (site 1: adjusted relative risk [aRR], 0.39; 95% CI, 0.34-0.44), but was positively associated with health plan disenrollment (aHR, 1.66; 95% CI, 1.24-2.22). The decreasing trajectory was not associated with mortality (aHR, 1.28; 95% CI, 0.87-1.86). In contrast, the high-dose increasing trajectory was positively associated with mortality (aHR, 2.19; 95% CI, 1.44-3.32) and opioid use disorder (aHR, 1.81; 95% CI, 1.39-2.37) but was not associated with disenrollment (aHR, 0.90; 95% CI, 0.56-1.42) or continued opioid therapy (site 1: aRR, 0.98; 95% CI, 0.94-1.03). Conclusions and Relevance: In this cohort study, decreasing opioid dose was associated with reduced risk of opioid use disorder and continued opioid therapy but increased risk of disenrollment compared with stable dosing, whereas the high-dose increasing trajectory was associated with an increased risk of mortality and opioid use disorder. These findings can inform opioid management decision-making.
- Subjects
WISCONSIN; COLORADO; CHRONIC pain; SUBSTANCE abuse; CONFIDENCE intervals; DRUG overdose; RETROSPECTIVE studies; ACQUISITION of data; STATE health plans; RISK assessment; RESEARCH funding; MEDICAL records; DESCRIPTIVE statistics; DRUG therapy; LONGITUDINAL method; PROPORTIONAL hazards models
- Publication
JAMA Network Open, 2022, Vol 5, Issue 10, pe2234671
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2022.34671