Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain

Ray, Wayne A.; Chung, Cecilia P.; Murray, Katherine T.; Hall, Kathi; Stein, C. Michael

doi:10.1001/jama.2016.7789

Cited by 321 publications

(281 citation statements)

References 37 publications

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“…Dosages of opioid and opioid/acetaminophen agents were combined during periods of overlapping possession, and we excluded values exceeding the 95th percentile of oral morphine equivalents. Periods of opioid exposure were then categorized as none (average daily total dose 0 mg), lower dose (0, average daily total dose #60 mg in oral morphine equivalents), or higher dose (average daily total dose .60 mg in oral morphine equivalents) (22).…”

Section: Exposure Variablesmentioning

confidence: 99%

“…In the general population, opioids have been associated with mortality as well as altered mental status, falls, and fractures (18)(19)(20)(21)(22), which may be mediated by the depressive effects of opioids on the respiratory and central nervous system and their association with decreased bone mineral density (22)(23)(24)(25)(26). Epidemiologic data regarding the risks of these major opioid complications in patients on hemodialysis are limited to three cohort studies, in which opioid use was associated with all-cause mortality, dialysis discontinuation, hospitalization, and fracture (27,28); also, opioid use was higher among those who experienced a fall, but it was not an independent predictor of fall (29).…”

Section: Introductionmentioning

confidence: 99%

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Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

Ishida

McCulloch

Steinman

et al. 2018

CJASN

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Background and objectives Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited.Design, setting, participants, & measurements Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (.60 mg, #60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment).Results The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture.Conclusions Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.

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Section: Exposure Variablesmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

Ishida

McCulloch

Steinman

et al. 2018

CJASN

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“…In conclusion, NIDA (2015), RIDOH (2016) and Ray et al, (2016) all illustrate the effects that opioids, drug abuse, addiction and dependence has on the health of a patient. Identified mortality related to opioids underscores the importance of instituting education on safe opioid prescribing.…”

Section: Mortality Related To Prescription Drug Use In the Usmentioning

confidence: 99%

“…A recent retrospective cohort study by Ray, Chung, Murray, Hall and Stein (2016) compared the cause of mortality in patients with chronic non-cancer pain who were prescribed a long-acting opioid, such as: sustained release morphine, controlled release oxycodone, transdermal fentanyl and methadone, as opposed to an alternative pharmacologic intervention for moderate to severe chronic pain. The study included Tennessee Medicaid enrollees initiating a therapy of either long-acting opioids or other alternative medicines from 1999 through 2012.…”

Section: Mortality Related To Prescription Drug Use In the Usmentioning

confidence: 99%

Safe Opiod Prescribing Guidelines for APRN Students

Chartier¹

2017

Preprint

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Advanced Practice Nurses (APRN) are the forefront of healthcare that provide care to individuals, families, groups and communities. With the opioid epidemic on the rise in Rhode Island and nationally, it is imperative to teach APRN students safe prescribing of opioids. The purpose of this study was to increase advanced practice nursing students' awareness and knowledge of safe opioid prescribing guidelines. The Instituting the CDC Guidelines for Prescribing Opioids for Chronic Pain in RIC graduate nursing school curriculum will increase APRN's knowledge and attitudes on safe prescribing. To date, there is diminutive research available on the knowledge and attitudes of APRN students on safe opioid prescribing. Further research is indicated.

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“…Studies of a few dozen to a few hundred patients are far too small to prove safety [16], especially when the serious complications we worry most about (here, drug overdose or addiction following surgery) are uncommon or rare. Having said that, it appears that exposure to narcotics after a surgical procedure will cause a surprisingly high proportion of previously narcotic-naïve patients to continue to use these drugs well after recovery is complete [1], and longacting narcotics may be especially dangerous [24]. Efficacy of long-acting narcotics as part of multimodal analgesic approaches likewise is questionable; as alluded to earlier, patients do not perceive improvements of <2 cm on a 10-cm VAS pain scale to be clinically important [13]; yet this is the effect size typically associated with the use of these drugs for this indication [5,8,15].…”

mentioning

confidence: 99%