By Dr. Geoffrey Modest
Two important articles were just published in NEJM which I think should stimulate a change in clinical practice regarding prescribed opiates.
One article assessed the relative importance of physician prescribed opiates and the subsequent use of opioids in the elderly (see Barnett ML. N Engl J Med 2017; 376: 663).
- Retrospective analysis of a random 20% sample of continuously-enrolled Medicare beneficiaries who had an emergency department (ED) visit from 2008-2011, and had not received opioid prescription for the prior six months
- Mean age 69, 65% female, 76% white, 50% also on Medicaid, 37% disabled, mean of 3.5 chronic conditions (most commonly hypertension in 78%, hyperlipidemia in 70%, acute MI in 50%, depression 40%, diabetes 38%, COPD 28%), with 38% from the South/24% Midwest/20% Northeast/17% West
- ED physicians at the hospitals were classified as either high-intensity or low-intensity opioid prescribers, according to their quartile of prescribing rates at that same hospital.
- The rates of continued opioid use were compared, defined as 180 days supplied in the 12 months after that ED visit
- 215,678 patients received treatment from low-intensity and 161,951 from high-intensity prescribers. The overall clinical characteristics of the patients treated by these different providers were very similar.
- Within individual hospitals, the opioid prescribing rates varied by the type of providers: 7.3% versus 24.1% (p<0.001), for the low versus high-intensity prescribers. There was minimal correlation between the physicians’ prescribing rate and the median initial dose of the opioid prescribed.
- There was a 30% increase in long-term use of opioids by patients treated by the high-intensity prescribers, adjusted odds ratio 1.30 (1.23-1.37), p<0.001. The number-needed-to-harm was 49 patients receiving an opioid prescription leading to one excess long-term opioid user.
- There was a stepwise increase in long-term opioid use, tracking with increased quartiles of physician prescribing rates.
- Those patients seeing a high-intensity opioid prescriber had higher rates of subsequent hospital encounters (a 3% significant increase) and encounters for fall or fracture (a 7% significant increase), with no difference in non-opioid-related encounters
- It is notable that the rates of hospitalizations for opioid overdoses in the elderly Medicare population has quadrupled from 1993 to 2012.
- It is also quite concerning that the elderly are more likely to have adverse consequences from even therapeutic doses of opioids, including more sedation, falls, fractures, and death from any cause.
- Although this was an observational study, which limited the rigor of its conclusions or its ability to determine causality, these researchers seem to have done an excellent job of including huge numbers of patients, comparing providers in the same institution with each other, and controlling well for likely comorbidities of the patients (though they don’t have a clear assessment of the intensity of the pain of the individual patients, it does seem unlikely that patients would be assigned to high-intensity opioid prescribers just because they had more pain and thereby creating a bias in the study)
- As noted in several prior blogs, one of my major concerns about opioid prescribing is the dearth of good clinical evidence. This leads to a not so infrequent clinical conundrum: what to do with an elderly patient who has significant chronic pain, perhaps from osteoarthritis, to the point that they have very limited function and extremely poor quality of life. Perhaps a trial of NSAIDs does not help (and NSAIDs have their own attendant morbidities), and neither does acetaminophen nor topical or other adjuvant therapies. Perhaps they have had multiple steroid injections with diminishing or limited effectiveness. And perhaps they are not interested in surgery, or are not healthy enough for it. As a result, to improve their quality of life and after extensive discussion of adverse effects, I have sometimes prescribed tramadol or codeine or even low-dose oxycodone, often in combination with other adjuvant therapies, with excellent clinical and quality-of-life results. And, I think that is in the patients’ best interests and is appropriate care. Even in patients who are 90+ years old.
- However, this article does reinforce the peril of prescribing opiates to the elderly. Given that the patients given opiates did not seem to differ clinically from those not given opiates, it pretty clearly suggests that we as providers may be playing a significant role in creating long-term opiate users. Our experience in Boston has shown pretty dramatic changes in ED opiate prescribing over the past couple of years. During that time period of this study, it was unusual for one of my patients who had gone to the ED for pain not to come home with an opiate prescription, even if they explicitly stated to the ED doctor that they did not want or need these meds. That is no longer the case. And we should all take seriously studies which show, for example, that even renal colic, considered one of the more severe pains, seems to respond to NSAIDs similarly to opiates (e.g., see Teichman JMH. New Engl J Med. 2004; 350: 684). And many patients do well with NSAIDs post-op (my clinical observation).
- Although the study targeted older patients, it is consistent with a prior blog in which adolescents with low risk of illicit drug dependence but given legitimate prescription opiates as 12th graders (for surgery, etc.), were up to 3-fold more likely to have opiate use disorder at age 23 (see http://blogs.bmj.com/bmjebmspotlight/2015/11/10/primary-care-corner-with-geoffrey-modest-md-prescribed-opioids-and-future-prescription-opioid-misuse-in-teens/ )
Given that clinicians seem to be more consciously decreasing/limiting their opiate prescriptions and more hesitant to start opiates, there not only may be fewer prescription opiates available on the street, but also fewer patients requesting/needing continued opiate prescriptions subsequently. So, the more optimistic take on this issue of opiate dependence is perhaps that the future is bright/there may be fewer people with opioid dependence going forward.
An editorial highlighted the huge public health threat of fentanyl (see Frank RG. N Engl J Med 2017; 376:605), making several important points:
- Fentanyl-related deaths have been increasing dramatically, especially in the eastern United States: from 2628 in 2012, to 5544 in 2014, with 41% of heroin-related deaths involving fentanyl
- Fentanyl is mixed with a multitude of street drugs, including heroin, MDMA (methylenedioxymethamphetamine), OxyContin, Xanax, and Narco (acetaminophen-hydrocodone). A recent Canadian analysis found that 89% of seized counterfeit OxyContin tablets contained fentanyl
- Fentanyl is cheap, going for $3500 per kilogram, as compared to $65,000 per kilogram for heroin (and this is despite heroin’s declining prices, which had made it much more attractive in the streets than prescribed opiates, such as Percocet)
- This all further supports harm reduction strategies, especially since most who die from fentanyl overdose are unaware they are taking it, including: improved monitoring of street drugs for fentanyl, drug enforcement approaches which emphasize use reduction (e.g., not targeting buyers with syringes, which may actually increase the risk of needle sharing and other higher-risk behaviors, etc.), improved access to treatment programs, improved access to naloxone (which, as per prior blogs, may need a higher dose for fentanyl overdoses).
- This article highlights the devastating and escalating effects of illicit fentanyl, apparently largely produced in China, emphasizing appropriately the importance of harm reduction as a key strategy
- Of note, I had been unaware that fentanyl was mixed with so many different street drugs, and not just with heroin. This article highlighted how widespread fentanyl-lacing can be, and this message needs to be transmitted to our drug-using population.
For relevant recent blogs:
http://blogs.bmj.com/bmjebmspotlight/2017/02/10/primary-care-corner-with-geoffrey-modest-md-increasing-deaths-from-opioids/ highlights the increasing opiate death rates, esp from fentanyl
http://blogs.bmj.com/bmjebmspotlight/2016/06/29/primary-care-corner-with-geoffrey-modest-md-tai-chi-for-knee-oa-mindfulness-for-chronic-pain/ describes a study looking at Tai Chi and mindfulness to treat chronic pain
http://blogs.bmj.com/bmjebmspotlight/2016/04/05/primary-care-corner-with-geoffrey-modest-md-meds-for-oa-including-placebo/ is an interesting study finding that even placebo works pretty well for chronic pain from osteoarthritis and, in general http://blogs.bmj.com/bmjebmspotlight/category/pain/ for a slew of articles on chronic pain and opiates, with descriptions and critiques of published guidelines