Discontinuation of Opioid Analgesics is Particularly Risky for Those With Mental Illness or Substance Use Disorders

Opioid analgesic prescribing has recently come under scrutiny in light of the overdose epidemic. Focused efforts encourage careful risk versus benefit evaluations when prescribing opioids and cessation when the risks exceed the benefits. Some studies show increases in deaths from suicide and overdose after opioid cessation. This large observational cohort study of mostly male US veterans (N=1.3 million) with an outpatient prescription for an opioid analgesic over 2 years assessed death from overdose or suicide based on length of time from opioid cessation, and length of opioid treatment.

• Overall, 57% of patients stopped receiving opioids during the time-frame; most had prescriptions for either <30 days (32%) or >400 days (37%).
• Patients who stopped opioids were mostly prescribed short-acting medications (70%); 15% had a documented substance use disorder and 43% had a documented mental health diagnosis (versus 14% and 49%, respectively, among patients who continued opioids).
• Opioid discontinuation was associated with an increased risk of death from overdose or suicide regardless of the length of opioid treatment, although risk increased with the longer the patient was prescribed opioids (hazard ratios [HRs]: 1.67 [≤30 days], 2.80 [31-90 days], 3.95 [91-400 days], and 6.77 [>400 days]).
• Death rates for overdose or suicide increased both after the initiation of and with the cessation of opioids, but these risks reduced after 3 months. Patients with substance use disorders (HR, 2.48) and mental health diagnoses (HR, 1.54) were at most risk for suicide or overdose.

Comments: Discontinuation of prescription opioid analgesic medications is a common clinical practice, particularly after surgery or acute injury, yet most prescribers receive little-to-no formal training in it. This study shows the importance of additional education in this area so that prescribers can support patients and offer evidence-based treatments when needed, particularly among patients who are prescribed longer-term opioid medications, or who have mental illness or substance use disorders. Importantly, the study did not report the racial or ethnic background of the patients, nor the specialty of the opioid prescriber; these data may further illuminate treatment and training gaps.

Melissa B. Weimer, DO, MCR

Reference: Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020;368:m283.