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*A LOT* of chatter in KOL community about these two articles this week...
Takeaways: Long-term opioid use is associated with long-term disability and tapering is associated with mental health crises and overdoses.
The Cost of Lost Productivity in an Opioid Utilizing Pain Sample
Published 4 August 2021 Volume 2021:14 Pages 2347—2357
Michael A Fishman,1 Ajay B Antony,2 Corey W Hunter,3 Jason E Pope,4 Peter S Staats,5 Rahul Agarwal,6 Allison T Connolly,6 Nirav Dalal,6 Timothy R Deer7
1Center for Interventional Pain and Spine, Exton, PA, USA; 2The Orthopaedic Institute, Gainesville, FL, USA; 3Ainsworth Institute of Pain Management, New York, NY, USA; 4Evolve Restorative Center, Santa Rosa, CA, USA; 5Premier Pain Centers, Shrewsbury, NJ, USA; 6Abbott, Sylmar, CA, USA; 7The Spine and Nerve Center of the Virginias, Charleston, WV, USA
Correspondence: Michael A Fishman
Center for Interventional Pain and Spine, 160 North Pointe Blvd Suite 208, Lancaster, PA, 17603, USA
Tel +1 917-543-6588
Email [email protected]
Background and Aims: Chronic pain affects more adults in the United States than any other condition. Opioid medications are widely used in the treatment of chronic pain, but there remains considerable risk and cost associated with their use. This study aims to characterize the effects of opioid prescribing for chronic pain and similar pain conditions on lost productivity in the United States.
Methods: This was a retrospective, longitudinal, observational study of chronic pain patients in 2011– 2014. We identified patients with a diagnosis of musculoskeletal pain receiving index prescription for opioids in administrative claims and studied disability absence in a linked health and productivity management database. Patients were grouped as de novo and continued use opioid users before index, and by opioid dose in the year after index. Days of disability were compared before and after index with bootstrapping. Effect of opioid dose group on disability was evaluated with negative binomial regression. Lost productivity cost was compared before and after index.
Results: The cohort contained 16,273 de novo and 6604 continued use patients. On average, de novo patients used 24.8 days of disability after index, an increase of 18.3 more days compared to before (p < 0.001). Continued use patients used 30.7 days after index, 9 more days than before (p < 0.001). There was a dose–response relationship between dose group and days of disability in de novo patients (p < 0.001). The weighted-average cost per person of lost productivity was $4344 higher in the year after index compared to the year before.
Conclusion: Opioid prescriptions for pain patients were associated with significant disability use and lost productivity costs. With the evolution of opioid-prescribing practices, CDC recommendations, and the HHS Pain Management Best Practices, there is opportunity to use alternative pain therapies without the risks of opioid-induced side effects to improve work productivity.
Keywords: opioids, pain, disability, productivity
Original Investigation
August 3, 2021
Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids
Alicia Agnoli, MD, MPH, MHS1,2; Guibo Xing, PhD2; Daniel J. Tancredi, PhD2,3; et alElizabeth Magnan, MD, PhD1,2; Anthony Jerant, MD1,2; Joshua J. Fenton, MD, MPH1,2,4
Author Affiliations
JAMA. 2021;326(5):411-419. doi:10.1001/jama.2021.11013
editorial comment icon Editorial
Comment
Full
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Key Points
Question In patients prescribed stable, long-term, high-dose opioid therapy, is dose tapering associated with an increased risk of overdose or mental health crisis?
Findings In this retrospective cohort study that included 113 618 patients prescribed stable, high-dose opioid therapy, patients in periods following dose tapering, compared with patients before or without tapering, had an adjusted incidence rate ratio of 1.68 for overdose and 2.28 for mental health crisis; both risks were statistically significant.
Meaning Opioid dose tapering was associated with increased risk for overdose and mental health crisis, but interpretation of these findings is limited by the study design.
Abstract
Importance Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis.
Objective To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids.
Design, Setting, and Participants Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion.
Exposures Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period.
Main Outcomes and Measures Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity.
Results The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21).
Conclusions and Relevance Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.
Takeaways: Long-term opioid use is associated with long-term disability and tapering is associated with mental health crises and overdoses.
The Cost of Lost Productivity in an Opioid Utilizing Pain Sample
Published 4 August 2021 Volume 2021:14 Pages 2347—2357
Michael A Fishman,1 Ajay B Antony,2 Corey W Hunter,3 Jason E Pope,4 Peter S Staats,5 Rahul Agarwal,6 Allison T Connolly,6 Nirav Dalal,6 Timothy R Deer7
1Center for Interventional Pain and Spine, Exton, PA, USA; 2The Orthopaedic Institute, Gainesville, FL, USA; 3Ainsworth Institute of Pain Management, New York, NY, USA; 4Evolve Restorative Center, Santa Rosa, CA, USA; 5Premier Pain Centers, Shrewsbury, NJ, USA; 6Abbott, Sylmar, CA, USA; 7The Spine and Nerve Center of the Virginias, Charleston, WV, USA
Correspondence: Michael A Fishman
Center for Interventional Pain and Spine, 160 North Pointe Blvd Suite 208, Lancaster, PA, 17603, USA
Tel +1 917-543-6588
Email [email protected]
Background and Aims: Chronic pain affects more adults in the United States than any other condition. Opioid medications are widely used in the treatment of chronic pain, but there remains considerable risk and cost associated with their use. This study aims to characterize the effects of opioid prescribing for chronic pain and similar pain conditions on lost productivity in the United States.
Methods: This was a retrospective, longitudinal, observational study of chronic pain patients in 2011– 2014. We identified patients with a diagnosis of musculoskeletal pain receiving index prescription for opioids in administrative claims and studied disability absence in a linked health and productivity management database. Patients were grouped as de novo and continued use opioid users before index, and by opioid dose in the year after index. Days of disability were compared before and after index with bootstrapping. Effect of opioid dose group on disability was evaluated with negative binomial regression. Lost productivity cost was compared before and after index.
Results: The cohort contained 16,273 de novo and 6604 continued use patients. On average, de novo patients used 24.8 days of disability after index, an increase of 18.3 more days compared to before (p < 0.001). Continued use patients used 30.7 days after index, 9 more days than before (p < 0.001). There was a dose–response relationship between dose group and days of disability in de novo patients (p < 0.001). The weighted-average cost per person of lost productivity was $4344 higher in the year after index compared to the year before.
Conclusion: Opioid prescriptions for pain patients were associated with significant disability use and lost productivity costs. With the evolution of opioid-prescribing practices, CDC recommendations, and the HHS Pain Management Best Practices, there is opportunity to use alternative pain therapies without the risks of opioid-induced side effects to improve work productivity.
Keywords: opioids, pain, disability, productivity
Original Investigation
August 3, 2021
Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids
Alicia Agnoli, MD, MPH, MHS1,2; Guibo Xing, PhD2; Daniel J. Tancredi, PhD2,3; et alElizabeth Magnan, MD, PhD1,2; Anthony Jerant, MD1,2; Joshua J. Fenton, MD, MPH1,2,4
Author Affiliations
JAMA. 2021;326(5):411-419. doi:10.1001/jama.2021.11013
editorial comment icon Editorial
Comment
Full
Text
Key Points
Question In patients prescribed stable, long-term, high-dose opioid therapy, is dose tapering associated with an increased risk of overdose or mental health crisis?
Findings In this retrospective cohort study that included 113 618 patients prescribed stable, high-dose opioid therapy, patients in periods following dose tapering, compared with patients before or without tapering, had an adjusted incidence rate ratio of 1.68 for overdose and 2.28 for mental health crisis; both risks were statistically significant.
Meaning Opioid dose tapering was associated with increased risk for overdose and mental health crisis, but interpretation of these findings is limited by the study design.
Abstract
Importance Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis.
Objective To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids.
Design, Setting, and Participants Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion.
Exposures Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period.
Main Outcomes and Measures Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity.
Results The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21).
Conclusions and Relevance Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.
