Clinical Cases Podcast Series-FREE NO CME-BMJ 2020 Tapering VA Study

BMJ 2020 Tapering VA Study

Pdf Summary

This BMJ observational evaluation examined whether stopping prescribed opioid analgesics is associated with subsequent death from overdose or suicide among US veterans treated in the Veterans Health Administration (VHA). Using VHA pharmacy and clinical data, the authors identified 1,394,102 patients who received an outpatient opioid prescription in fiscal year 2013 and followed them through fiscal year 2014, linking outcomes to National Death Index cause-of-death data. Opioid cessation was defined as the estimated date a patient no longer had pills available, and length of the last opioid treatment episode was categorized as 30, 31–90, 91–400, or >400 days.<br /><br />Across the cohort, 2,887 overdose or suicide deaths occurred (1,851 overdose and 1,249 suicide, not mutually exclusive). Overall, 57.4% of patients stopped opioid treatment during follow-up. In multivariable Cox non-proportional hazards models, stopping opioids was associated with increased risk of overdose or suicide death for all treatment durations, with risk rising markedly as prior treatment length increased. Estimated hazard ratios for those who stopped opioids were 1.67 after 30 days of treatment, 2.80 after 31–90 days, 3.95 after 91–400 days, and 6.77 after >400 days. Sensitivity analyses showed the same pattern for overdose and suicide outcomes examined separately.<br /><br />Life-table analyses suggested elevated death rates immediately after both starting and stopping opioids, with the highest vulnerability concentrated in the first ~3 months and tapering over 3–12 months. The authors emphasize these associations are not necessarily causal because reasons for initiation or discontinuation (eg, worsening illness, mental health or substance use instability) were not measured. They conclude that clinical guidelines should more explicitly address risk mitigation—monitoring, suicide/overdose prevention, and care continuity—particularly for at least three months after opioid starts or stops, and especially after long-term therapy.

Keywords

opioid cessation

veterans health administration

overdose death

suicide death

observational study

hazard ratio

prescribed opioids

treatment duration

risk mitigation

National Death Index