Veterans at Higher Risk of Overdose/Suicide Death After Stopping Opioid Treatment; Increasing Risk with Duration on Opioids
VA's safety initiatives produced a 37% reduction in opioid prescribing between 2014 and 2016, largely by a reduction in the initiation of long-term use of opioids, but also from reductions among some long-term recipients. This study examined the associations between stopping outpatient opioid treatment, length of opioid treatment, and overdose/suicide death among VA patients. Focusing on the early implementation period of VA's opioid safety initiative, investigators used VA data to identify Veterans with any outpatient opioid analgesic prescription during FY2013 (n=1,394,089), as well as mortality rates due to overdose or suicide through FY2014. [Opioids specifically for treating opioid use disorder were excluded.] Among patients prescribed an opioid analgesic in FY2013, 10% of VA patients were prescribed long-acting opioids, 68% were prescribed short-acting opioids, and 22% were prescribed tramadol only. Length of opioid treatment was categorized as â‰¤30 days, 31-90 days, 91-400 days, and >400 days. Patient comorbidities were also assessed.
- Veterans were at a higher risk of overdose/suicide death after stopping opioid treatment, with increasing risk the longer they had been treated before stopping. Even patients treated for up to 30 days had a rise in risk of death after treatment was stopped.
- The following factors also were independently associated with a higher risk for overdose/suicide death: receiving prescriptions for long-acting or short-acting opioids compared to tramadol; maximum daily morphine milligram equivalents; number of medical diagnoses; and having a mental health disorder diagnosis or substance use disorder diagnosis. Older age, female gender, and being currently married were independently associated with a lower risk for overdose/suicide death.
- Risk of death from overdose or suicide was increased for 3 months after starting or stopping treatment with opioids, highlighting these vulnerable risk periods.
- Opioid safety efforts should take a broader patient safety perspective and consider risk mitigation from a patient-centered perspective, such as addressing risk factors other than opioid prescriptions, especially in the first three months post-initiation and post-cessation.
- This observational study cannot prove cause and effect and is subject to unmeasured confounding.
- The opioid cessation variable used in this study did not take into consideration the clinical intentionality or reasons for cessation, or the speed of its execution.
- The data are at least seven years old and may not reflect recent quality improvement initiatives.
This study was supported through VA’s Office of Mental Health and Suicide Prevention (OMHSP). Drs. Oliva and Bowe are part of HSR&D’s Center for Innovation to Implementation.
Oliva E, 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. British Medical Journal. March 4, 2020; Epub ahead of print.