(C-073) Barriers and Facilitators to Deprescribing Opioids in High-Risk Older Adults: A comparison based on cirrhosis status

Background: Older adults with cirrhosis frequently rely on prescription opioids because they are disproportionately burdened with pain-related disability compared to those without cirrhosis. United States policy and practice changes in 2014 and 2016 encouraged opioid discontinuation and tapering in high-risk populations, but it remains unclear how this guidance affected those with cirrhosis.

Objectives: Our objective was to describe the trends in opioid deprescribing and tapering among older adults with long-term (>90 days) opioid use. We compared rates and predictors based on cirrhosis status.

Methods: In this retrospective cohort study, we used a U.S sample of fee-for-service Medicare beneficiaries from January 2013 to December 2018 (N=7,641,629). Our included sample represents N=327,702 adults aged 65 years or older with chronic pain and no history of cancer or terminal illness. The exposure was cirrhosis status, defined according to claims-based diagnoses and prescription fills. The primary outcome was days until opioid discontinuation (i.e., a refill gap > 30 days). Tapering (i.e., a 35% decrease in average opioid dose) was the secondary outcome. We estimated discontinuation rates with the Kaplan-Meier method, predictors for time until opioid discontinuation with proportional hazards regression, and tapering predictors with logistic regression. We assessed 42 predictors measured in the 6-months before cohort entry. We used Fine and Grey’s method to address competing risks, inverse probability of censoring weights to handle informative censoring, and varied refill gap durations and tapering decreases in sensitivity analyses.

Results: In our sample (Mean age [SD]=75 [8] years, female=67%, White=86%), N=4,272 had compensated cirrhosis and N=2,805 had decompensated cirrhosis. After one year, 38% (95%CI=38%-38%) of individuals without cirrhosis discontinued opioids, but only 32% (31%-34%) with compensated and 34% (31%-36%) with decompensated cirrhosis discontinued. Compared to 2014, by 2018, discontinuation was 29% (HR 95% CI=1.26-1.32) more likely among those without cirrhosis, but 19% (1.01-1.41) in those with any cirrhosis. In those with cirrhosis, an age of 70-77 (HRs, 0.89 [0.80-0.99]) and ≥78 (HRs, 0.87 [0.77-0.99]) years decreased the likelihood of opioid discontinuation compared to those 65-69 years old. Non-steroidal anti-inflammatory drugs and skilled rehabilitation were the only pain treatments that predicted discontinuation and tapering.

Conclusions: Opioid discontinuation rates are lower in older adults with cirrhosis, compared to those without cirrhosis. Safe analgesic alternatives are needed to facilitate opioid discontinuation among the cirrhosis population.