Ceasing treatment with opioids is associated with an increased risk of death from overdose and suicide, an observational study from the United States has found.

A total of 1,394,102 patients, mean age 60 years, in the Veterans Health Administration system who had received outpatient prescriptions for an opioid medication during the 2013 fiscal year were included in the study. Data on death rates up to the end of the fiscal year 2014 were analysed. The vast majority of participants were men (92%). Just over half the patients had three or more medical diagnoses. Alcohol use disorders were diagnosed in about 10% of patients and the most common mental health conditions were depressive disorders and post-traumatic stress disorder.

There were 2,887 deaths from overdose or suicide (1,851 overdoses and 1,249 suicides, these figures were not mutually exclusive). Just over half of patients (57.4%) stopped opioid treatment during the study period.

Patients had been prescribed opioids for variable periods, and the longest period identified, longer than 400 days, accounted for 37% of patients. Around a third (32%) of patients were prescribed opioids for up to 30 days, 9% for 31-90 days and 23% for 91-400 days.

The hazard ratios (HR) for death by overdose or suicide for patients who stopped opioid treatment were:

• HR 1.67 for ≤ 30 days’ opioid treatment

• HR 2.80 for 31-90 days’ opioid treatment

• HR 3.95 for 91-400 days’ opioid treatment

• HR 6.77 for > 400 days’ opioid treatment

Other factors that were independently associated with a greater risk of death from overdose or suicide were: prescriptions for long- or short-acting opioids as opposed to tramadol; log maximum daily morphine mg equivalents; the number of medical diagnoses; and having a mental health or substance use disorder. Older age, female gender, and being married were independently associated with a lower risk of death from overdose or suicide.

Concerns about recent rapid increases in the prescribing of opioid medication, particularly for chronic non-cancer pain, and associated risks such as overdose and dependence, has led to a range of initiatives to support clinicians in reducing and stopping prescribing opioids when appropriate.

The authors conclude that: ‘Patient-centred efforts to mitigate the risk of death from overdose or suicide in patients prescribed opioids need to look at a broad array of risk factors for patients rather than focus solely on long-term prescription management. Our findings suggest close monitoring for at least three months for any patient stopping treatment with opioids but especially in those on long-term treatment or those with other risk factors (e.g. mental health and substance use disorders)’.

Dr Jez Thompson