Opioid Prescribing Practices in Chronic Kidney Disease

A Population-Based Cohort Study

Amber O. Molnar; Sarah E. Bota; Kyla Naylor; Danielle M. Nash; Graham Smith; Rita S. Suri; Manish M. Sood; Tara Gomes; Amit X. Garg


Nephrol Dial Transplant. 2022;37(12):2408-2417. 

In This Article

Abstract and Introduction


Background: Chronic pain is common, and its management is complex in patients with chronic kidney disease (CKD), but limited data are available on opioid prescribing. We examined opioid prescribing for non-cancer and non-end-of-life care in patients with CKD.

Methods: This was a population-based retrospective cohort study using administrative databases in Ontario, Canada which included adults with CKD defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 from 1 November 2012 to 31 December 2018 and estimated the proportion of opioid prescriptions (type, duration, dose, potentially inappropriate prescribing, etc.) within 1 year of cohort entry. Prescriptions had to precede dialysis, kidney transplant or death.

Results: We included 680 445 adults with CKD, and 198 063 (29.1%) were prescribed opioids. Codeine (14.9%) and hydromorphone (7.2%) were the most common opioids. Among opioid users, 24.3% had repeated or long-term use, 26.1% were prescribed high doses and 56.8% were new users. Opioid users were more likely to be female, had cardiac disease or a mental health diagnosis, and had more healthcare visits. The proportions for potentially inappropriate prescribing indicators varied (e.g. 50.1% with eGFR <30 were prescribed codeine, and 20.6% of opioid users were concurrently prescribed benzodiazepines, while 7.2% with eGFR <30 mL/min/1.73 m2 were prescribed morphine, and 7.0% were received more than one opioid concurrently). Opioid prescriptions declined with time (2013 cohort: 31.1% versus 2018 cohort: 24.5%; p <0.0001), as did indicators of potentially inappropriate prescribing.

Conclusions: Opioid use was common in patients with CKD. While opioid prescriptions and potentially inappropriate prescribing have declined in recent years, interventions to improve pain management without the use of opioids and education on safer prescribing practices are needed.


In Canada, between 2016 and 2021, there were >24 000 apparent opioid-related deaths.[1,2] The opioid crisis is a complex and evolving issue, with both illicit and prescription opioids contributing to the crisis.[3–6] Recognizing the potential serious harms of prescription opioids, recent opioid guidelines strongly recommend optimizing non-opioid and non-pharmacological therapies prior to a trial of opioids for the treatment of chronic non-cancer pain.[7] In chronic opioid users, it is recommended that a dose reduction be attempted or opioids be discontinued where possible in collaboration with the patient.[7]

Chronic pain is a common symptom reported by patients with chronic kidney disease (CKD).[8,9] However, high-quality data and established guidelines that inform pain management in CKD are lacking, and many analgesics are contraindicated or require dose adjustment, which increases the risk of inappropriate opioid prescribing and drug-related adverse events.[10,11–16] Specifically, non-steroidal anti-inflammatory drugs (NSAIDs), a first-line agent for non-cancer pain, are contraindicated in patients with CKD,[17–19] which limits analgesic options and may lead to both under-treatment of chronic pain and increased opioid use.[20–22] There is a paucity of data on opioid prescribing practices in patients with CKD; published studies are mostly small or limited to patients on hemodialysis.[10,20,23–27] Two prior large American studies examined opioid use in non-dialysis CKD up until 2016 and reported a high prevalence of use with variations by region, year and CKD severity.[21,22]

Given that opioid use may differ by country and prescribing has likely changed since 2016, we conducted a population-based study to examine opioid prescribing for non-cancer, non-end-of-life care, including type of opioid, duration of opioid use, high-dose opioid use and various indicators of potentially inappropriate opioid prescribing, in patients with CKD in Ontario, Canada.