Stopping opioid treatment linked to increased risk of death from overdose or suicide in veterans

The risk of death from overdose or suicide increased immediately after starting or stopping opioids and continued to rise the longer patients were treated with opioids.

Patients may be at greater risk of death from overdose or suicide after stopping opioid treatment, with a higher risk among those treated with opioids for a longer duration, a study found.

Researchers examined associations among stopping treatment with opioids, length of treatment (≤30 d, 31 to 90 d, 91 to 400 d, and >400 d), and death from overdose or suicide in nearly 1.4 million patients in the Veterans Health Administration (VHA). Study participants had an outpatient prescription for an opioid analgesic from Oct. 1, 2012, to Sept. 30, 2014. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids up to the end of fiscal year 2014 or the patient's death. Results were published March 4 by The BMJ.

Overall, 2,887 patients died of overdose or suicide, and the incidence of stopping opioid treatment was 57.4% (n=799,668). By length of opioid treatment, the proportion of patients was 32.0% for treatment of 30 days or less, 8.7% for 31 to 90 days, 22.7% for 91 to 400 days, and 36.6% for more than 400 days. Patients had an increased risk of death from overdose or suicide after stopping treatment, and the risk increased the longer patients were treated with opioids. Hazard ratios for patients who stopped opioid treatment were 1.67 (≤30 d), 2.80 (31 to 90 d), 3.95 (91 to 400 d), and 6.77 (>400 d). Descriptive data suggested that starting treatment with opioids was also a risk period for death from overdose or suicide, with the incidence decreasing over about three to 12 months.

Among other limitations, the study had an observational design and was unable to account for the reasons or clinical intentions for stopping treatment with opioids, the study authors said.

In response to these findings, the VHA educated its clinicians and launched a medication use evaluation on opioid tapering to further assess opioid cessation, according to a linked opinion piece by the study authors. In addition, the health system updated its clinical decision support systems to help identify and safely manage patients with recent opioid cessation and later expanded its opioid safety initiative to consider patient risk factors from a holistic perspective.

“A key take-home message is that addressing the opioid crisis requires us to move beyond solely focusing on opioids,” they wrote. “Factors associated with increased risk when patients are prescribed opioids are also associated with risk when opioids are no longer part of the patient's treatment plan (e.g. mental health disorders, medical complexity, other medications).”