Long-Term Opioid Use Linked to Increased ED Visits, Drug and Alcohol Problems

Caroline Cassels

September 15, 2010

September 15, 2010 — Long-term opioid therapy with schedule II opioids for chronic noncancer pain appears to increase the risk for emergency department visits (EDVs) and drug- and alcohol-related problems, new research suggests.

Investigators at the University of Washington School of Medicine in Seattle found that schedule II opioids, headache, back pain, and preexisting substance use disorders were all significantly associated with EDVs and alcohol- or drug-related encounters (ADEs) in adults prescribed opioids for 90 days or more.

"Among [chronic opioid therapy (COT)] users, previously diagnosed substance use disorders and opioid types were the variables most strongly associated with ED visits and ADEs in the subsequent year. Any use of short-acting Schedule II opioids was associated with a higher number of ED visits, while any use of long-acting Schedule II opioids was associated with more ADEs," the investigators write.

Jennifer Brennan Braden, MD, MPH, is the first author of the study, which appears in the September 13 issue of the Archives of Internal Medicine.

Increase in Abuse, Deaths

According to the study, COT is commonly used to manage chronic noncancer pain. At the same time, the authors note, there has been an increase in reported opioid abuse and deaths from prescription opioid overdose. However, they add, the link between opioid prescribing and adverse outcomes is unclear.

"Deaths related to prescription opioid use might be owing to abuse and diversion of these medications, or they might be purely accidental. Demographic and clinical factors associated with increased adverse medical outcomes among COT prescription recipients are unknown," they write.

To examine the prevalence and risk factors for ED use among COT patients, the investigators analyzed data derived from administrative claim records between January 2001 and December 31, 2004, from a state Medicaid population and a multistate commercially insured population.

The study sample included 38,491 commercially insured individuals and 10,159 Medicaid enrollees. All subjects were aged 18 years or older and had used opioids for at least 90 continuous days during a 6-month period.

Investigators found that on average, patients undergoing COT were middle-aged and mainly women. At 36.8% and 50.2%, the most prevalent diagnosis was back pain in both the private insurance and Medicaid groups, respectively.

Among the privately insured group, 24.2% visited the ED within 12 months of initiating COT vs 28.2% of Medicaid enrollees. The investigators also found that 1.6% of the private insurance group and 2.6% of Medicaid recipients were treated for ADEs within 12 months of starting COT.

The authors report that patients receiving COT with a previously diagnosed substance use disorder were at particularly high risk for ED use and ADEs.

"[T]hose with a substance use disorder diagnosis in the preceding year had from 18% to 73% more ED utilization and were 3 to 5 times more likely to have an ADE," the investigators write.

Need for Recommended Maximum Dose

Any use of short-acting schedule II opioids was associated with a higher number of EDVs. In contrast, any use of long-acting schedule II opioids was associated with more alcohol- and drug-related events.

Although opioid dose per day was not consistently associated with EDVs, it doubled the risk for ADEs at morphine-equivalent does higher than 120 mg/day, the authors report.

The investigators suggest that "it may be possible to increase the safety of chronic opioid therapy by minimizing the prescription of Schedule II opioids in these higher risk recipients."

Dr. Mitchell H. Katz, MD, form the San Francisco Department of Public Health, in California, agrees. In an accompanying editorial, Dr. Katz calls for consensus guidelines to establish a recommended maximum dose in patients with nonmalignant pain.

"It is not reasonable or fair to expect practising clinicians to hold the line on opioid prescriptions, given that [current] consensus guidelines fail to define any upper limit on dosing," Dr. Katz writes.

Dr. Katz also asserts that an upper recommended dosing limit would reduce harm by "eliminating the highest doses that have been associated with the highest likelihood of overdose."

The authors and Dr. Katz have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:1425-1432, 1422-1424. Abstract Abstract


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