Nurses who think tapering opioid patients entails a long period of Defcon 2 or 3 vigilance now have more data to support that position.
Researchers from the UC Davis Center for Healthcare Policy and Research conducted a 10-year study to examine the potential long-term risks of opioid dose tapering. They found that patients on stable but higher-dose opioid therapy who had their doses tapered by at least 15% had significantly higher rates of overdose and mental health crisis in the second year after tapering compared to their pre-tapering period.
Opioid therapy and the push to reduce the dose of pain medication
Changes in prescribing guidelines and regulatory policies driven by the rise in opioid-related deaths have led many physicians to reduce daily doses for patients on stable opioid therapy for chronic pain. The dose reduction process – called tapering – has been linked to worsened pain, symptoms of opioid withdrawal and depressed mood among some patients.
“While patients may struggle during the early tapering period, we reasoned that many may stabilize with longer-term follow-up and have lower rates of overdose and mental health crisis once a lower opioid dose is achieved,” said Joshua Fenton, professor and vice-chair of research in the Department of Family and Community Medicine at UC Davis School of Medicine and lead author of the study. “Our findings suggest that, for most tapering patients, elevated risks of overdose and mental health crisis persist for up to two years after taper initiation.”
Pain management and the risks of dose changes
To draw associations between dose reductions and changes in the risk for overdose and mental health visits, the researchers used a database covering a 10-year period (2008-2017) for more than 28,000 patients prescribed long-term opioids. They examined enrollment records and medical and pharmacy claims for patients prescribed stable high opioid doses (the equivalent of at least 50 morphine milligrams per day) and who had their doses reduced by at least 15%.
From this patient cohort, they selected those who had at least one month of follow-up during the second year of their post-tapering period. They identified a total of 21,515 tapering events for 19,377 patients.
Those events included emergency department visits or inpatient hospital admissions for drug overdose, withdrawal, or mental health crisis events, such as depression, anxiety or suicide attempts. The team compared rates of these events in the pre-tapering period with those during the second taper year of follow-up after tapering initiation.
“We used an innovative observational study design to understand the patients’ experience before and after opioid dose reduction. We compared outcome rates in pre- and post-taper periods with patients serving as their own controls,” said pediatrics professor Daniel Tancredi, co-author of the study. “This design has the advantage of controlling for patient characteristics that may influence relationships between tapering and adverse events.”
The study found that for every 100 patients, there was an average of 3.5 overdose or withdrawal events and 3 mental health crises during the pre-tapering period, compared to 5.4 events and 4.4 crises in the 12-24 months post-tapering period. That’s a 57% increase in overdose or withdrawal incidents and a 52% increase in mental health crises. The risks of tapering were greatest in patients with the highest baseline doses.
Long-term follow-up and support for patients on reduced pain therapy
In 2018, the Department of Health and Human Services (HHS) issued guidelines to advise clinicians to monitor patients carefully during tapering and provide psychosocial support. They recommended close follow-up and cautioned about the potential risks of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress.
This new study emphasized the need for clinicians and patients to discuss dose reduction and carefully weigh the risks and benefits of opioid continuation and tapering. Tapered patients would benefit from close follow-up and monitoring not only in the short term but in the long term too, to make sure they’re coping well on lower doses.
“We hope this work will inform a more cautious approach to decisions around opioid dose tapering,” Fenton said. “While our results suggest that all tapering patients may benefit from monitoring and support up to two years after taper initiation, patients prescribed higher doses may benefit from more intensive support and monitoring, particularly for depression and suicidality.”
Other UC Davis Health collaborators include Elizabeth Magnan, Iraklis Erik Tseregounis, Guibo Xing and Alicia Agnoli. The study was supported by a University of California–OptumLabs Research Credit, the Department of Family and Community Medicine at UC Davis, and the UC Davis School of Medicine Dean’s Office (Dean’s Scholarship in Women’s Health Research BIRCWH/K12).
Rogelio Lopez, who has been hospitalized for more than a year, had just one birthday wish.
He wanted to see his four children, ages 6, 9, 11 and 13, in person.
So, last Thursday, after intensive planning by his team of caregivers, Lopez was placed on a portable ventilator and wheeled on a hospital bed from Tower 6 to the main entrance of UC Davis Medical Center. There he enjoyed a tearful reunion with his kids.
Roughly 15 additional family members joined in the festivity, including his siblings and nephews. And to add to the party atmosphere, a mariachi ensemble played celebratory songs in honor of Lopez, who turned 38.
“Rogelio smiled as his four kids caressed and hugged him, as it had been more than a year since they had seen their father, all together, in person,” said Yesenia Ramos, a UC Davis resident physician who serves on a team of doctors training to care for patients in urban, underserved aeras. “The doctors, nurses, respiratory therapists and others tearfully watched this touching reunion.”
Dayshift Assistant Nurse Manager Ashley Dotger, a go-between for the family and staff, called the celebration a gratifying experience for nurses.
“I think the nurses on Tower 6 med-surg take great pride in being able to give great care to those who have extended stays,” she said. “It is humbling to be a part of somebody’s life when they’re struggling.”
In video filmed by Ramos, Lopez appears on his bed with a colorful, striped blanket covering his legs, while being escorted outside by six staffers wearing face shields. They reunite him with his family where the assembled mariachis, heavy on trumpets, play “Las Mañanitas,” a popular birthday song. Lopez’ older family members surround the bed while children holding “Happy Birthday” balloons greet their dad, one by one.
Lopez has been unable to speak but his sister, Lourdes Lopez, who coordinated the event for the family, said her brother deeply appreciated the celebration.
“It was incredible and emotional to see him laugh,” she said. “The kids didn’t want to leave, the time seemed really short to them,” she added.
Lopez’s medical ordeal began in December 2020 when he returned from vacation in Mexico and showed up at the Sacramento County Health Centercomplaining of puffy legs, a swollen stomach and shortness of breath.
“He was hoping to get better with just medication,” recalled Lisandra Franco, a primary care doctor who also is an attending physician to the medical center’s residents in the TEACH program, or Transforming Education and Community Health.
She knew better.
Because Lopez had diabetes and worsening kidney problems, Franco sent him to the emergency room. Within days of being admitted, Lopez started dialysis. Then he contracted COVID-19 pneumonia requiring intubation, developed bacteremia, had heart valve surgery, suffered a heart attack, encountered lung problems, a gastrointestinal bleed and multiple other health issues that are not easy to solve.
“He’s definitely gone through a lot of challenges while he’s been in the hospital,” Franco said. “He’s still trying to get better every day for his children, and it’s really touching to see that.”
When caregivers met with Lopez over the summer to discuss his uncertain prognosis, they learned about how much he missed his children, who haven’t all been able to visit together due to COVID-19 restrictions. Lopez, who is estranged from his wife, told his care team that if he was still hospitalized on Dec. 30, he wanted to spend part of his birthday with his children.
Lourdes Lopez, who visits her brother’s bedside every evening, envisioned a birthday celebration. She shared her idea with her siblings, one of whom suggested they hire mariachis like Mexican families do for weddings and other life milestones. Unfortunately, the brother who suggested mariachis was unable to see his plan come to fruition – Lourdes Lopez said he died from COVID-19 not long after.
Pulling off the celebration was a well-orchestrated collaboration involving physicians, nurses, respiratory therapists, language interpreters, a transportation team, child life specialists, social workers and administrators.
“This simple transport outside takes a team approach, an attribute which UC Davis does exceptionally well,” explained Dotger in an email to other nurses and leaders before the event. “We are very excited to make this possibility for this long-term patient.”
Franco, the attending physician, said Lopez is the kind of patient that doctors and staff will never forget.
“It feels really good to be able to work at a place like UC Davis,” Franco said. “Obviously, medical treatment is one of the important aspects of patient care, but you can’t forget the human part of medicine, which is treating each patient with empathy and respect. UC Davis really focuses on that aspect of patient care.”
Prevention strategies and vaccinations reduced transmission by vaccinated workers with breakthrough infections
A new study shows vaccinated healthcare workers who had breakthrough COVID-19 infections are at low risk of transmitting the virus to patients and colleagues in a health care setting.
The research showed infection prevention strategies such as symptom screening, universal masking and social distancing per the Centers for Disease Control and Prevention (CDC) recommendations, coupled with a highly vaccinated workforce substantially reduced the risk of transmission by vaccinated people working while infectious.
“The results of our study show that layering infection prevention strategies is highly effective in limiting secondary cases among vaccinated individuals,” said Sarah Waldman, assistant clinical professor of Infectious Diseases at UC Davis Health and lead author of the study. “This suggests adoption of such strategies in community settings, including masking and social distancing, could substantially mitigate secondary infections among vaccinated individuals in the community and all work environments.”
For the study, Waldman teamed up with Stuart Cohen, chief of the Division of Infectious Diseases at UC Davis, and infectious disease experts at UC San Francisco, UC Irvine and UCLA.
The team evaluated breakthrough COVID-19 infections in vaccinated health care staff during the Delta variant surge in California from June 1 – July 26, 2021. They assessed cases at four large academic medical centers in the University of California system (UC Davis, UC Irvine, UC Los Angeles, and UC San Francisco). Staff were defined as all health care employees, both patient care and nonpatient care, plus trainees and students.
Among the four health systems, there were 88,570 health care workers. The overall vaccination rate was 82%, with the vast majority having received mRNA vaccines. A total of 11,836 workers underwent COVID-19 testing, of which 3.7% were confirmed to have COVID-19 infections. The overall breakthrough case rate among vaccinated staff members was 0.43% during the study period.
“In those for whom we had data available, the predominant suspected source of their infection was community acquisition,” said Waldman. “The numbers showed COVID-19 cases among the health care workers were largely driven by social gatherings and household exposures occurring outside of the health care setting.”
Overall, COVID-19 infections among vaccinated health care workers contributed to an average of 1.73 work-related exposures per health system at a ratio of 29% patients and 71% staff. The overall proportion of secondary cases due to vaccine breakthrough disease was just 0.75%.
“The important message that needs to be taken from this study is that patients should feel safe seeking medical care, despite the surge of the Delta variant,” said Waldman. “It also highlights the importance for all individuals to get vaccinated and continue to use a layered approach to prevent spread of the virus by masking and social distancing when in public.”
Throughout the pandemic, many people skipped routine preventive care and screenings out of fear of COVID-19 exposure. UC Davis Health and community organizations are working to ensure people get the tests they need.
One great example is a partnership between SETA Head Start and the Betty Irene Moore School of Nursing at UC Davis. When administrators at SETA wanted to ensure their staff were keeping up on annual tuberculosis (TB) screenings, they tapped into a partnership with the School of Nursing and its second-year nursing students.
Located in Del Paso Heights, SETA Head Start provides low-income children with quality comprehensive child development services that are family focused, including education, health, nutrition and mental health.
For two weeks in July, future registered nurses in their fifth quarter of an 18-month accelerated program administered and read the results of TB tests for more than 100 of the organization’s staff.
“The goal of our Fostering Healthy Communities course is to combine nursing theory and clinical care with an emphasis on working with diverse communities in providing health promotion and chronic disease management,” said Shana Ruggenberg, director of the Master’s Entry Program in Nursing. “This experience offers a tangible opportunity to put classroom and lab experience into real practice.”
Students develop their motor skills and learn how to administer an intradermal injection. But the lesson goes far beyond that.
“We learn about these readings in theory, read about it in the textbooks but now we’re out seeing it in person. This brings the school to life,” explained student Judy Njuguna.
“I think this is where we practice the most important aspect of nursing – getting to interact with people. We can pretend to do that in a simulation by talking to a patient simulator or having another student pretend to be a patient. But this is real – we’re using real interpersonal skills,” added student Ju-A Son.
SETA Head Start is not a clinical facility. In order to make the on-site clinics possible, the School of Nursing leveraged UC Davis Heath’s relationship with Elica’s Health on Wheels mobile medicine program. The mobile health van is part of a health system partnership launched in 2017. The goal is to expand access to care for underserved and hard-to-reach patients, and those who can’t see providers regularly due to transportation issues, homelessness or other barriers.
For these screenings, Elica provided logistics, a space for mass testing opportunities, the medical materials required to properly administer the injections and access to experienced medical staff members providing care in a non-traditional setting. Plus, the students learned different techniques on care delivery. TB testing requires an injection of tuberculin under the skin, then a recheck in three days to see if the virus is present.
“I think that allowing nursing students the opportunity to participate in this type of outreach can help them to gain a better understanding of their community,” said Aidé Long, director of Elica’s Community Outreach Services. “This could potentially help them to narrow down the area of nursing they would like to specialize in by helping them gain experience out in the field.”
TB is a communicable disease and the leading cause of death in the world from a single infectious agent, according to the World Health Organization. It’s also curable and preventable. But the COVID-19 pandemic threatens to reverse global progress against TB. That’s why SETA administrators wanted to make sure their staff had access to screening.
SETA and the School of Nursing have partnered for five years. Graduate students have educated Head Start families on health and wellness, conducted growth assessment for pre-school-aged children and emphasized the importance of primary care prevention. These encounters support the nursing program’s goal of exposing students to population-based health promotion and disease prevention strategies with diverse individuals, families, communities and populations.
“TB testing is required for staff on an annual basis to keep enrolled children and staff safe from infectious diseases,” said Gricelda Ocegueda, SETA’s health and nutrition coordinator. “These screenings provided access, offered opportunities to educate our team about TB, ensured our program is in compliance and presented an educational experience for the UC Davis students. Education and awareness of vulnerable populations are important for these students to learn early in their careers in health.”
The critical thinking, clinical excellence and a deep understanding of the health care system that graduates gain enable them to flourish. Programs and experiences such as this prepare students to advance health locally, nationally, and globally in ways that address inequities, big and small, that stand in the way of optimal health and health care equity for all.
“This particular experience also showed students the challenges and barriers to providing health care in under-resourced community areas,” Ruggenberg explained.
The face-to-face encounters with those being tested — both when administered and read — also presented teachable moments from the students that a classroom cannot.
“I grew up in this area, but I didn’t even know SETA was here,” said student Kou Her. “This was really eye-opening for me to learn what’s in my own neighborhood. It’s just a great experience to hands-on serve my community.”
Opioid therapy is complex. In recent years, a rise in opioid-related deaths and changing prescribing guidelines and regulatory policies have led many physicians to reduce daily doses for patients prescribed stable opioid therapy for chronic pain.
Some patients have reported that this dose reduction process—called tapering –has been difficult, sometimes involving worsened pain, symptoms of opioid withdrawal and depressed mood.
In a study published Aug. 3 in JAMA, a team of UC Davis Health researchers examined the potential risks of opioid dose tapering. Their study found that patients on stable opioid therapy who had their doses tapered had significantly higher rates of overdose and mental health crisis, compared to patients without dose reductions.
“Prescribers are really in a difficult position. There are conflicting desires of ameliorating pain among patients while reducing the risk of adverse outcomes related to prescriptions,” said Alicia Agnoli, assistant professor of Family and Community Medicine at UC Davis School of Medicine and first author on the study. “Our study shows an increased risk of overdose and mental health crisis following dose reduction. It suggests that patients undergoing tapering need significant support to safely reduce or discontinue their opioids.”
De-prescribing opioids for patients on long-term therapy
The study used enrollment records and medical and pharmacy claims for 113,618 patients prescribed stable higher opioid doses (the equivalent of at least 50 morphine milligrams per day) for a one-year baseline period and at least two months of follow-up.
It looked at emergency department visits or inpatient hospital admissions for any drug overdose, alcohol intoxication, or drug withdrawal and for mental health crisis events such as depression, anxiety, or suicide attempts.
The researchers compared outcomes for patients after dose tapering to those for patients before or without tapering. They found a 68% increase in overdose events and a doubling of mental health crises among tapered as compared to non-tapered patients. The risks of tapering were greater in patients who had faster dose reductions and higher baseline doses.
To taper or not to taper
Guidelines from the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) advise clinicians to monitor patients carefully during tapering and provide psychosocial support. They caution about the potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress.
“Our study results support the recent federal guidelines for clinicians considering opioid dose reduction for patients,” said Joshua Fenton, professor and Vice Chair of Research in the Department of Family and Community Medicine and senior author on the study. “But I fear that most tapering patients aren’t receiving close follow-up and monitoring to make sure they’re coping well on lower doses.”
The researchers emphasized the need for clinicians and patients to carefully weigh the risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy.
“We hope that this work will inform a more cautious and compassionate approach to decisions around opioid dose tapering,” Agnoli said. “Our study may help shape clinical guidelines on patient selection for tapering, optimal rates of dose reduction, and how best to monitor and support patients during periods of dose transition.”