Chronic pain impacts more than one in four American adults over age 65 and is commonly managed by long-term opioid treatment. But as the opioid overdose epidemic spirals up in this country, more clinicians are turning down prescriptions for their use.

This means that millions of patients in chronic pain are also being removed from long-term opioid treatment (LTOT), often faster than recommended—raising concerns this is leading to undertreated pain, mental health crises and suicide. Others are losing their opioid treatments because their clinicians are leaving the workforce.

A new study led by SHP’s Adrienne Sabety, PhD, an assistant professor of health policy, a faculty research fellow at the National Bureau of Economic Research, and a faculty fellow at the Stanford Institute for Economic Policy Research, finds that a sudden loss of an opioid prescription due to a prescriber leaving the workforce can lead to an uptick in short-term mental health crises, such as suicide attempts and admissions to hospitals and emergency departments. The cessation, however, does not appear to lead to a significant change in the rate of overdose or mortality—and the immediate negative outcomes taper off after several months.

“Our paper shows that discontinuation from LTOT is far less harmful than previously thought,” said Sabety. “While some intermediary outcomes worsen—like mental health crises and hospital utilization—mortality does not increase.”

The study, published online at BMJ, moves beyond existing ones because the researchers used a method to account for patients being discontinued from opioids being different from those not discontinued. For example, a patient may be discontinued because prescribers suspect that patients are bordering on behavioral, substance use, or mental health disorders, whereas patients who continued LTOT are maintaining baseline.

“Without robust evidence that accounts for selection and confounding, clinical knowledge on the association between LTOT discontinuation and patient outcomes is incomplete, impeding both therapeutic management of LTOT and the development of opioid policy,” writes Sabety and her coauthors, Hannah Neprash of the University of Minnesota, Marema Gaye and Michael Barnett of Harvard University.

The cohort study used a 20% random sample of Medicare fee-for-service and Medicare Advantage beneficiaries from 2011 through 2018. They excluded cancer patients and data with missing racial status—accounting for less than 1% of the sample. They looked at 48,079 people receiving LTOT whose prescriber stopped providing office-based patient care or who had exited the workforce, perhaps through retirement or death. They then they looked at the same number of people whose prescriber did not exit the workforce.

Because their findings differed from previous evidence that did not control for unobserved confounding, the consequences of LTOT discontinuation varies depending on the study methods used.

“Our paper underscores how the choice of methods can give different results, making it hard for patients and policymakers to manage the clinical and public health challenges of LTOT,” Sabety said. “This variation underscores the importance of randomized interventions to better understand how LTOT discontinuation can be managed safely and effectively.”