Exposure to High-Risk Medications is Associated With Worse Outcomes in Older Veterans With Chronic Pain

Abstract

Background Chronic pain is common, costly, and leads to significant morbidity in older adults, yet we have limited data on medication safety. We sought to evaluate the association of incident High Risk Medication in the Elderly (HRME) with mortality, emergency department (ED) or hospital care among older adults with chronic pain. Methods A retrospective Veterans Health Administration cohort study was conducted examining older Veterans with chronic pain diagnoses and use of incident HRME (opioids, skeletal muscle relaxants, antihistamines, and psychotropics). Outcomes evaluated included all-cause mortality, ED visits, or inpatient hospital care. Descriptive statistics summarized variables for the overall cohort, the chronic pain cohort, and those with and without HRME. Separate generalized linear mixed-effect regression models were used to examine the association of incident HRME on each outcome, controlling for potential confounders. Results Among 1,807,404 Veterans who received VA care in 2005–2006, 584,066 (32.3%) had chronic pain; 45,945 Veterans with chronic pain (7.9%) had incident HRME exposure. The strongest significant associations of incident HRME were for: high-risk opioids with all-cause hospitalizations (OR 2.08, 95%CI 1.95–2.23); skeletal muscle relaxants with all-cause ED visits (OR 2.62, 95%CI 2.52–2.73) and mortality (OR 0.80, 95%CI 0.74–0.86); antihistamines with all-cause ED visits (OR 2.82 95%CI 2.72–2.95); and psychotropics with all-cause hospitalizations (OR 2.15, 95%CI 1.96–2.35). Conclusions Our data indicate that incident HRME is associated with clinically important adverse outcomes in older Veterans with chronic pain and highlight the importance of being judicious with prescribing certain classes of drugs in this vulnerable population.

Identifying Treatment Effect Modifiers in the STarT Back Trial: A Secondary Analysis

“…Our findings reflect exploratory evidence that should be interpreted with caution and not considered as confirmatory as the factors selected for this secondary analysis were based on theory and previous research. 59 For example, lower education level 8, 16, 76 and increased number of pain medications 23, 51 have demonstrated prognostic capabilities for musculoskeletal pain related clinical outcomes in previous studies, however were only identified as having weak evidence to modify treatment response in our analysis. Future studies are required to confirm these findings prior to changes in clinical practice.…”

“…28 Gurung, et al 28 identified younger age, being employed or in sedentary occupations, less narcotic medication use, higher levels of education, and greater positive treatment expectations as potential treatment effect modifiers for positive LBP treatment response using data generated from four randomized trials. In addition, prognostic capabilities associated with lower education level 8, 16, 76 and using an increased number of pain medications 23, 51 have been reported for musculoskeletal pain clinical outcomes in previous studies that have not specifically tested for treatment effect modification. Collectively, our findings support the need for further exploration of treatment effect modification through adequately powered studies and these should include patient level factors such as education level and use of pain medications.…”

“…We hypothesized that prognostic stratified care would be less effective compared to current best care for patients that reported using three or more pain medications. 23, 25, 26, 38, 51, 61 …”

Nutraceutical-based Integrative Medicine: Adopting a Mediterranean Diet Pyramid for Attaining Healthy Ageing in Veterans with Disabilities

“…Inappropriate prescriptions [97][98][99][100] and potential prescription omissions [98] have also been documented. Moreover, multiple medications are frequently used in patients with PTSD and traumatic brain injury [101,102], as well as in the management of chronic pain [103][104][105][106].…”

Pharmacotherapies in Geriatric Chronic Pain Management

“…63 Further, a recent retrospective cohort study in older (>65 years of age) Veterans showed that muscle relaxants (including methocarbamol and cyclobenzaprine, among others) were associated with increased risk for emergency department visits as well as all-cause hospitalizations (including those for falls and fractures). 85 Another commonly used agent used for spasticity, and not included in the Beer’s criteria, is baclofen. Baclofen is a centrally acting skeletal muscle relaxant with an FDA indication to treat spasticity related to CNS lesions; dosing regimens vary by indication.…”