Factors Associated With Abrupt Discontinuation of Long-Term High-Dose Opioid Treatment

This cohort study investigates factors associated with abrupt discontinuation of long-term high-dose opioid treatment at the national level and across US states.


Introduction
Managing long-term high-dose (LTHD) opioid regimens is a concern. 1 The repercussions of abrupt discontinuation are profound, encompassing adverse outcomes such as withdrawal, illicit substance use, and mental health complications. 2,3Research shows that a notable majority of patients, exceeding 70% nationwide, encounter abrupt discontinuation of LTHD treatments, 4 which signals potential gaps in management strategies.This study aims to identify factors associated with abrupt discontinuation, extending previous research [4][5][6] by incorporating more recent data and identifying their associations at the national level and across states.

Methods
This cohort study followed the STROBE reporting guideline and was exempt from review and granted waiver of informed consent by the Mass General Brigham institutional review board because data were not obtained through participant interaction.We analyzed a sample from the IQVIA Longitudinal Prescription database to identify opioid treatment episodes that started in January 2014 or later and had been discontinued by September 2020.We examined all data for the following year (through September 2021) to ensure participants remained continuously enrolled.LTHD episodes were defined as lasting at least 90 days with at least 90 daily morphine milligram equivalents (DMME) for at least 14 consecutive days. 4Episodes were abruptly discontinued if the final 30 days' DMME was at least 60 or represented a greater than 35% reduction compared with the previous 30 days (eMethods in Supplement 1).Associations between abrupt discontinuation and race and ethnicity, age, sex, payment source, initial opioid dosage (included to control for clinical decisions), and year of discontinuation were analyzed using multivariable logistic regressions at national and state levels.Race and ethnicity data were collected to identify disparities among different races and ethnicities.

+ Supplemental content
Author affiliations and article information are listed at the end of this article.
Open Access.This is an open access article distributed under the terms of the CC-BY License.

Discussion
Our national-level cohort study identified a significant risk of abrupt discontinuation, with the associated sociodemographic factors consistent with prior research. 4We also found that abrupt discontinuation occurred less frequently over time, suggesting that clinicians have responded to concerns about the risks associated with this practice.Additionally, our study found large heterogeneities across states, which were distinct from the national-level results.At the state level, sociodemographic factors most often associated with abrupt discontinuation were being male and a Black patient.
A limitation of our study is the lack of data on rationale for dosage adjustments, treatment discontinuation, and information on patient behavior, especially whether having received guidance from the physician on tapering within the last high-dosage prescription.However, we would not   expect Black or male patients to consistently have conditions or practices that would make abrupt discontinuation more appropriate for them than for White or female patients.Thus, it is likely our findings point to real disparities.Further analysis should investigate the reasons for the disparities and why they exist in some states but not others.

Figure . Factors
Figure.Factors Associated With Abrupt Discontinuation of Long-Term High-Dose Opioid Treatment Episodes at the State Level In 9 states, Black patients had a higher likelihood of abrupt discontinuation than White patients, and a lower risk in 1 state (Figure); Hispanic patients had a higher risk in 2 states.Abrupt discontinuation was more likely among male patients in 12 states(Figure).Compared with Medicaid enrollees, cash payers faced a higher risk in 6 states.In only 1 state were patients with private insurance at higher risk, whereas Medicare patients were at higher risk in 2 states.Starting with DMME greater than or equal to 120 was associated with increased risk of abrupt discontinuation in 48 states and the District of Columbia.Twenty-nine states had a decrease over time in abrupt discontinuations.