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A new study published in JAMA looked at the long-term risk of overdose or mental health crisis after opioid dose tapering.

“We have published results showing that opioid tapering after long-term stable dosing was associated with overdose and mental health crisis events during a one-year follow-up period,” study author Joshua J. Fenton told us. “We wanted to assess the longer-term outcomes associated with tapering.”

According to the Centers of Disease Control and Prevention, substance use is on the rise and has continued to increase at higher rates during the pandemic. From 1999-2019, nearly 500,000 people in the US died from an opioid overdose. Though the US government does not track death rates for every drug, the CDC along with the National Institute on Drug Abuse does for certain drugs including opioids. In 1999-2020, nearly 92,000 people in the US died from a drug overdose including the use of opioids and illicit drugs.

The researchers hypothesized that, in the longer run, opioid dose reduction might actually be associated with reduced risks as patients grow accustomed to lower opioid doses. The researchers extended the follow-up on the patients who tapered in their original cohort study to examine associated risks up to two years after taper initiation.

“Due to the opioid overdose crisis and many state and local policy changes, clinicians are increasingly reducing opioid doses in patients prescribed long-term opioid doses,” Fenton told us. “Previously, little was known about the clinical outcomes associated with tapering. While clinicians were hoping tapering would reduce risks, we now know that tapering is associated with higher overdose and mental health risks, at least in the short run.”

Researchers compared patients’ rates of overdose and mental health crisis during a period 13-24 months after taper initiation to the rates during a period of baseline opioid dosing prior to tapering.

During the post-taper long-term follow-up period, patients’ rates of overdose and mental health remained substantially elevated as compared to the period prior to dose tapering.

“The results were contrary to our hypothesis and suggest that patients who undergo tapering remain at elevated risks of adverse events up to two years after taper initiation,” Fenton told us. “The study results suggest that patients who are undergoing dose tapering should be carefully monitored for substance misuse and worsening mental health. Tapering patients should receive frequent and regular follow-up, and ongoing continuing care is a priority. Clinicians and patients should consider and discuss these risks prior to embarking on opioid tapering. Clinicians should also follow HHS guidelines on tapering, which suggest gradual dose reduction for most patients with regular reassessment of patients during tapering.”

The current study, and others in the field, are observational studies, and with these research designs, one can’t know whether observed risks are due to tapering, patient characteristics that prompt the decision to taper, or a mix of these factors. Nevertheless, the research clearly shows that the population of patients undergoing tapering is at high risk for both overdose events and mental health deterioration. Greater clinician awareness and careful monitoring may mitigate these risks.