Mortality After Discontinuation of Primary Care–Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study
Despite known risks of using chronic opioid therapy (COT) for pain, the risks of discontinuation of COT are largely uncharacterized.
To evaluate mortality, prescription opioid use, and primary care utilization of patients discontinued from COT, compared with patients maintained on opioids.
Retrospective cohort study of patients with chronic pain enrolled in an opioid registry as of May 2010.
Patients with chronic pain enrolled in the opioid registry of a primary care clinic at an urban safety-net hospital in Seattle, WA.
Main Outcomes and Measures
Discontinuation from the opioid registry was the exposure of interest. Pre-specified main outcomes included mortality, prescription and primary care utilization data, and reasons for discontinuation. Data was collected through March 2015.
The study cohort comprised 572 patients with a mean age of 54.9 ± 10.1 years. COT was discontinued in 344 patients (60.1%); 254 (73.8%) discontinued patients subsequently filled at least one opioid prescription in Washington State, and 187 (54.4%) continued to visit the clinic. During the study period, 119 (20.8%) registry patients died, and 21 (3.7%) died of definite or possible overdose: 17 (4.9%) discontinued patients died of overdose, whereas 4 (1.75%) retained patients died of overdose. Most patients had at least one provider-initiated reason for COT discontinuation. Discontinuation of COT was associated with a hazard ratio for death of 1.35 (95% CI, 0.92 to 1.98, p = 0.122) and for overdose death of 2.94 (1.01–8.61, p = 0.049), after adjusting for age and race.
In this cohort of patients prescribed COT for chronic pain, mortality was high. Discontinuation of COT did not reduce risk of death and was associated with increased risk of overdose death. Improved clinical strategies, including multimodal pain management and treatment of opioid use disorder, may be needed for this high-risk group.
KEY WORDSchronic pain primary care addiction
Our sincere appreciation to the following contributors: Greta Sweney, RPh, BCPS; Theresa O’Young, PharmD, BCPS; the many Adult Medicine Clinic providers who care for patients with chronic pain; and all the Adult Medicine Clinic patients whose lives have been affected by opioids.
Chart review, data abstraction, and analytic support were provided by the University of Washington School of Medicine’s Medical Student Research Training Program, the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1 TR002319, and the Division of General Internal Medicine at the University of Washington.
Compliance with Ethical Standards
The study was approved by the Institutional Review Board at the University of Washington.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
No funding source had any role in study design, conduct, or reporting. This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
- 2.Warner M. Trends in Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 1999–2012. Health E-Stats. 2014.Google Scholar
- 4.Chou R DR, Devine B, Hansen R, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/Technology Assessment. (No 218).Google Scholar
- 7.Group WSAMD, (AMDG). Interagency Guideline on Prescribing Opioids for Pain. 2015.Google Scholar
- 9.Hedegaard H, Warner M, Minino AM. Drug overdose deaths in the United States, 1999-2016. NCHS Data Brief. 2017;2016(No 294)Google Scholar
- 10.Group AMD. Opioid Dose Calculator.Google Scholar
- 15.Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1–49.Google Scholar
- 18.Hoffman J. Medicare is cracking down on opioids. Doctors fear pain patients will suffer. New York Times. 2018.Google Scholar
- 19.Darnall BD, Juurlink D, Kerns RD, et al. International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering. Pain Med. 2019;20(3):429–433.Google Scholar
- 20.Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 2014;30(7):557–564.Google Scholar