Reducing opioid dose — but not risk stratification or monitoring initiatives — may be effective in reducing overdose rates in patients on chronic opioid therapy, although this observed reduction was not significant compared with the group receiving a control intervention, according to a study published in The Journal of Pain.

Risk stratification and risk-based monitoring, 2 measures that are recommended as part of guidelines on chronic opioid therapy, are thought to be broadly adapted in the clinic. Previous studies have shown that prescription opioid overdose risk increases with opioid dosage. This is the first controlled study to examine the effects on opioid overdose rates of dose reduction initiatives during chronic opioid therapy. 

A total of 31,142 patients undergoing chronic opioid therapy for chronic noncancer pain (22,673 patients receiving an intervention and 8,469 individuals in a control group) were enrolled in the study. All participants were ≥18 years at the beginning of the study and had been enrolled in Group Health for ≥1 year. The primary analysis included current enrollees who had a ≥70-day supply of opioids (defined as chronic opioid therapy) and excluded patients who had received ≥2 cancer diagnoses within 1 year in the prior 3 years and/or patients who had a hospice claim. Intervention consisted of implementation of a reduction in opioid dose, or implementation of risk monitoring or risk stratification.

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An interrupted time series design was used to compare trends in overdose rates. Over the course of the study, the average daily morphine equivalent dose decreased by 47%, from 75.8 mg to 40.0 mg in intervention settings vs a 30% decrease in control settings, from 92.1 mg to 64.6 mg. Risk-based monitoring initiatives “increased rates of urine drug test, increased the documentation of care plans in electronic health records, required patients to request opioid refills several days in advance, fixed a single prescriber as responsible for managing chronic opioid therapy, and implemented online training of primary care clinicians.”

From 2006 to 2014, 311 participants experienced fatal or nonfatal opioid overdoses. In primary analyses, no significant difference between intervention  and control settings was observed. Differences between control and intervention were inconsistent, but a decrease in overdose rates in the intervention setting was observed during dose reduction. In planned secondary analyses, overdose rates declined at an average of 17% per year during dose reduction intervention (relative annual change, 0.83; 95% CI, 0.70-0.99), but not in control settings (relative annual change, 0.98; 95% CI, 0.70-1.39).

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Dose reduction interventions had inconsistent results in this study, but may represent an avenue for decreasing overdose rates in patients on chronic opioid therapy.  Disclosures: Multiple authors declare affiliations with the pharmaceutical industry. Please refer to reference for a complete list of authors’ disclosures.

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Von Korff M, Saunders K, Dublin S, et al. Impact of chronic opioid therapy risk reduction initiatives on opioid overdose [published online September 3, 2018]. J Pain. doi: 10.1016/j.jpain.2018.08.003