Sociogeographic determinants of rapid opioid reduction or discontinuation among patients on high-dose long-term opioid therapy in North Carolina, 2006-2018.

Abstract

Objective: Rapid opioid reduction or discontinuation among patients on high-dose long-term opioid therapy (HD-LTOT) is associated with increased risk of heroin use, overdose, opioid use disorder, and mental health crises. We examined the association of residential segregation and health care access with rapid opioid reduction or discontinuation among patients on HD-LTOT and examined effect measure modification of individual-level characteristics.

Methods: Using 2006-2018 North Carolina private insurance claims data, we conducted a retrospective cohort study of patients who were 18-64 years of age and on HD-LTOT (≥90 morphine milligram equivalents for 81 of 90 consecutive days), with 1-year follow-up. The outcome was rapid opioid reduction or discontinuation (versus maintenance, increase, or gradual reduction/discontinuation). Individual-level characteristics included age, sex, and clinical diagnoses (post-traumatic stress disorder [PTSD], depression, anxiety, and substance use disorder). Neighborhood-level characteristics included health care access (measured as geographic distance to health care facilities) and residential segregation (operationalized with the Index of Concentration at the Extremes). We conducted bivariate linear regression to estimate 1-year risk differences and 95% confidence intervals.

Results: Of 13 375 patients on HD-LTOT, 48.6% experienced rapid opioid reduction or discontinuation during 1-year follow-up. Female patients and those diagnosed with PTSD who lived in areas of least racial and economic privilege had higher risks of rapid opioid reduction or discontinuation than did those living in areas with the most racial and economic privilege.

Conclusion: Health care providers need to address potential biases toward patients living in underserved and marginalized communities, as well as intersectionality with mental health stigma, by prioritizing training and education in delivering unbiased care during opioid tapering.