- Researchers say overdose risks increase after opioid pain relievers are discontinued.
- Experts say the medical profession has been debating for more than a decade about when opioids should be given to people for pain relief.
- They note that there are other ways to reduce pain without using medications.
- They add that in most cases it’s best to slowly reduce a person’s dosage as they prepare to stop taking the painkillers.
A new study says opioid overdose risk increases when opioid pain relievers are discontinued for both people with and without opioid use disorder.
In their report, the study authors said discontinuing prescribed opioids was associated with increased overdose risk.
The findings, which were published today in the journal PLOS Medicine, indicated that opioid-related overdose is now a leading cause of accidental death in the United States and Canada, something that caused both countries to implement guidelines restricting opioid prescribing for chronic pain.
The researchers did a cohort study of people receiving long-term opioid therapy for pain in British Columbia between October 2014 and June 2018.
They looked at the medical histories of 14,037 people registered with the provincial health insurance client roster in British Columbia who were on opioid therapy for at least 90 days.
The team reported that discontinuing opioid therapy for pain was associated with increased overdose risk among people without opioid use disorder. They added that the chances for overdose were even high for those with the disorder, including those both receiving opioid agonist therapy and those not receiving treatment.
Those receiving tapering opioid treatment were associated with decreased risk of overdose in those with opioid use disorder who didn’t receive opioid agonist therapy.
Opioid agonist therapy uses medication, such as methadone, to help manage withdrawal symptoms.
The authors noted their study had several limitations, including the fact the outcome measure didn’t capture overdose events that didn’t involve healthcare intervention or those that resulted in death.
Researchers also said they couldn’t determine the source of the drugs involved in overdoses and whether they were prescribed or obtained illegally.
“These findings point to the need to avoid abrupt discontinuation of opioid treatment for pain and to enhance guidance for prescribers in modifying opioid treatment tapering strategies on the basis of opioid use disorder and opioid agonist therapy status,” the study’s authors wrote.
“Given the increased risk of overdose, sudden discontinuation of opioid treatment for chronic pain should be avoided in almost all instances,” the study authors added. “Enhanced guidance is needed to support prescribers in implementing safe and effective opioid for pain tapering strategies, with particular consideration of opioid use disorder and prescribed opioid agonist therapy status.”
Dr. Joseph Volpicelli, the executive director of the Volpicelli Institute of Addiction Medicine in Pennsylvania, told Healthline the healthcare industry has a long history of “ambivalence” about prescribing opioids for pain.
“Somewhere around 2010, the alarming rate of opioid overdoses caused us to rethink the medical use of opioids to treat pain and so the pendulum swung the other way,” Volpicelli said. “Healthcare professionals were increasingly reluctant to use opioids to treat pain and, in many cases, found that pain could be effectively relieved with behavioral and non-opioid medications.”
When doctors began cutting off prescriptions, they may have underestimated what happened next: users experiencing severe withdrawal and, in lieu of having prescriptions, turning to street drugs such as heroin.
“In 2010 there were 81 opioid prescriptions for every 100 people and this dramatically fell during the decade to 43 prescriptions per 100 people,” Volpicelli noted. “By 2015, the number of people dying from prescription opioids stopped increasing, but there was a dramatic increase in people dying from heroin overdose.”
“We are now in a third wave of the opioid overdose epidemic, as the highly potent and dangerous synthetic opioid fentanyl has replaced prescription opioids and heroin as the predominant illicit opioid,” Volplicelli said.
A big question now is when do opioids go from being safely prescribed to addictive problems.
“Every patient is different and has different needs,” Farah Khorassani, PharmD, a doctor of pharmacy at the University of California Irvine School of Pharmacy and Pharmaceutical Services, told Healthline.
“Repeated administration of opioids can induce dependence, but this happens at different times for different people depending on diagnosis, psychological conditioning, environmental, and neurobiological factors,” Khorassani added.
Experts say a person’s tolerance for a drug goes up with use, requiring higher doses and making it more difficult to quit. Starting to use again brings an unexpected effect.
“Once a person detoxes from opioids, many don’t realize that they can’t tolerate the same doses they did before they quit,” Khorassani said. “They can end up taking too high of a dose and that can lead to an overdose, where you see suppression of their respiratory system.”
Another question is how long prescriptions should last before there’s a danger of addiction.
“From 7 to 21 days would be a good time frame for someone to be taking an opiate for the purpose of acute pain relief,” said James S. Pratty, a psychologist specializing in addiction medicine and the medical director of behavioral health for Brand New Day healthcare.
“Hopefully during that time, the doctor has been instructing the patient that they should gradually decrease their frequency of taking the opiate over those 7 to 21 days,” Pratty told Healthline. “Opiates are not indicated for chronic pain and other interventions including physical therapy, yoga, and trigger point injections are a better intervention for chronic pain issues.”
Aaron Weiner is an addiction psychologist and president of the Society of Addiction Psychology. He told Healthline the most important key to avoiding opiate addiction is to be aware of the signs and symptoms and communicate with your doctor.
“If you do develop a mild chemical dependence on opioids, the good news is that you can likely taper yourself off the medications slowly – under guidance from your physician – and avoid any highly negative consequences,” Weiner told said.
“We also now have numerous treatments and medications that can potentially help you if a regular taper isn’t working for you,” he added. “Again, the most important part is to communicate with your physician to access these resources – if you try to hide the dependency from your healthcare team and it ends up growing and becoming worse, you could be in for a much steeper slope for recovery and potentially numerous negative consequences.”