Reasons for Opioid Discontinuation and Unintended Consequences Following Opioid Discontinuation Within the TOPCARE Trial. Issue 7 (27th June 2018)

• Record Type: Journal Article
• Authors: Husain, Jawad M; LaRochelle, Marc; Keosaian, Julia; Xuan, Ziming; Lasser, Karen E; Liebschutz, Jane M
• Is Part Of: Pain medicine. Volume 20:Issue 7(2019)
• Page Start: 1330
• Page End: 1337
• Publication Date: 2018-06-27
• Subjects: Opioids -- Chronic Pain -- Discontinuation -- Discontinuing -- Taper -- TOPCARE; Pain -- Periodicals; Pain -- Treatment -- Periodicals; Analgesics -- Periodicals; Pain -- Periodicals; Pain Management -- Periodicals; Douleur -- Périodiques; Douleur -- Traitement -- Périodiques; Analgésiques -- Périodiques; Analgésique; Soulagement de la douleur; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); 616.047205
• DOI: 10.1093/pm/pny124
• Languages: English
• ISSNs: 1526-2375

Abstract

Abstract : This study is a subgroup analysis that evaluated reasons for opioid discontinuation and post-discontinuation outcomes amongst patients in the Transforming Opioid Prescribing in Primary Care (TOPCARE) RCT. TOPCARE was a multicomponent clinical intervention to improve adherence to opioid prescribing guidelines. TOPCARE intervention patients showed a trend toward higher opioid discontinuation rates due to aberrancies in monitoring. However, they also showed decreased return to follow up, thus highlighting a potential unintended consequence of the intervention. Abstract: Objective: To identify reasons for opioid discontinuation and post-discontinuation outcomes among patients in the Transforming Opioid Prescribing in Primary Care (TOPCARE) study. Design: In TOPCARE, an intervention to improve adherence to opioid prescribing guidelines, randomized intervention primary care providers (PCPs) received nurse care manager support, an electronic registry, academic detailing, and electronic tools, and control PCPs received electronic tools only. Setting: Four Boston safety net primary care practices. Subjects: Patients in both TOPCARE study arms who discontinued opioid therapy during the trial. Methods: Through chart review, we examined the reason for discontinuation and post-discontinuation outcomes: one or more PCP visits, one or more pain-related emergency department (ED) visits, evidence of opioid use disorder (OUD), and referral for OUD treatment. Results: Opioid discontinuations occurred in 83/586 (14.2%) intervention and 42/399 (10.5%) control patients ( P = 0.09). Among patients who discontinued opioids, 81 (65%) discontinued for misuse, with no difference by group ( P = 0.38). Aberrancy in monitoring (e.g., discordant urine drug test results) was the most common type of misuse prompting discontinuation (occurring in (51/83 [61%] of intervention patients vs 19/42 [45%, P = 0.08] of control patients). Intervention patients who discontinued opioids had less PCP follow-up (65% vs 88%, P < 0.01) compared with control patients. We found no differences between groups for pain-related ED visits, evidence of OUD, or OUD treatment referral following discontinuation. Conclusions: The decreased follow-up among TOPCARE intervention patients who discontinued opioids highlights the need to understand unintended consequences of involuntary opioid discontinuations resulting from interventions to reduce opioid risk.