An Australian study assessed the 5-year trajectory for continued opiate use after initiating opiate therapy, finding that older persons were more likely to continue using opiates (see opioid use older people more likely to continue JAMA2023 in dropbox, or doi:10.1001/jamanetworkopen.2023.28159)
Details:
-- 3.57 million people were evaluated who initiated opiates from July 2013 to December 2018 but continued opiate use for at least 12 months afterwards, in a population-based study (the POPPY II study, with a database of 7.9 million people)
-- a 10% random sample was accessed, utilizing Australia’s Pharmaceutical Benefits Scheme to evaluate continuing opiate prescriptions (Australia has a universal health care system, with inclusive databases for prescription meds)
-- opiates dispensed included: buprenorphine, codeine, dextropropoxyphene, fentanyl, hydromorphone, methadone, oxycodone, pethidine, tapentadol and tramadol
-- people with a cancer diagnosis were excluded, as well as those on buprenorphine or methadone to treat opioid dependence
-- mean age 50, 53% female, 26% were at least 65yo, 71% lived in major cities.
-- relative socioeconomic disadvantage: 1st quintile (most disadvantaged) 20%; 2nd 20%, 3rd 23%, 4th 19%, 5th 16%
-- comorbidities assessed: cardiovascular (mostly hyperlipidemia and hypertension), endocrine (mostly diabetes), psych (mostly depression and anxiety), musculoskeletal (mostly osteoporosis), and respiratory (mostly asthma)
-- main outcome: trajectory of monthly opiate use over 60 months from opiate initiation, with assessment of individual differences
Results:
-- Overall 11,323 (2.6%) of people initiating opiates became sustained opiate users
-- opiate usage (not specifically defined): -- very low use: 75.4% (largest percentage in younger individuals; this very low use group was also more likely to get acetaminophen with codeine: 65% vs 30% in the sustained use group)
-- low use (16%)
-- moderate use, decreasing to low use (2.6%)
-- sustained use: 2.8% (more likely to get buprenorphine than in the very low use group: 12% vs 0.6%; also more likely to get >100 OME initially: 72% vs 26%)
-- use of transdermal preparations: 17% in sustained use group vs 1% in very low use group
-- total OME (oral morphine equivalents) given initially, comparing the percentages of people who were initially on high OME vs low, and subsequently became either sustained vs very low opiate users (see the article for the complete breakdown by opiate usage groupings:
-- <100 OME: 26% on this OME who subsequently had sustained opiate use vs 72% in those who had very low opiate usage
-- 100-249 OME: 40% vs 21%
-- 250-499 OME: 17% vs 5%
-- 500-749 OME: 6% vs 1%
-- >749 OME: 11% vs 1%
-- overall predictors of sustained opiate use :
-- initiation of opiates with a transdermal formulation: odds ratio 4.2 (3.9-4.5)
-- initiation with a total oral morphine equivalents of at least 750mg: OR 3.7 (3.3-4.1)
-- having depression: OR 1.6 (1.5-1.7)
-- having psychotic illness: OR 2.0 (1.8-2.1)
-- effect of meds previously prescribed:
-- acetaminophen (paracetamol): OR 2.0 (1.9-2.1)
-- pregabalin: OR 2.0 (1.8-2.1)
-- benzodiazepines: OR 1.53 (1.4-1.6)
-- age:
-- >75yo, OR 2.5 (2.3-2.6), as compared to those 18-44yo
Commentary:
-- in Australia, 3 million people are given opiate prescriptions annually, and 1.9 million initiate opiates annually
-- this study was impressive since they published longer term results, assessing the trajectory of opiate prescriptions over 5 years by age groups as well as prior meds, depression/psychoses, types/quantity of opiates prescribed.
-- 92% of their cohort received very low or low opiate prescriptions (ie, overall vast majority had low opiate dose meds and for a time-limited period)
-- individuals with sustained opioid use were older, had more comorbidities, and higher use of other analgesics before opioid initiation
-- those who were at least 75yo were 2.5 times more likely to be persistent opiate users than those 18-44yo
-- there was an interesting US study of older patients receiving opiates in the emergency room in the US, where those patients seeing a high-opiate-prescriber vs low-opiate-prescriber for similar clinical complaints were 30% more likely to be taking opiates 6 months later: http://gmodestmedblogs.blogspot.com/2017/02/opiate-prescribing-in-elderly-and.html
-- there are many potential explanations as to why older people might continue with opiates:
-- many older people may be less able to initiate nonmedical therapies (exercise, PT, etc) than younger ones
-- many may not be able to tolerate NSAIDs for a variety of reasons: hypertension, heart failure, GI bleeding, CKD...
-- many may shift their focus in the clinical encounter away from their now-controlled pain to more pressing and concerning issues
-- and many may fear that stopping the opiates will bring back their prior pain
-- But:
-- studies have found that opiates are really no better for many of the acute and chronic pain indications than non-opiates or nonpharmacologic approaches
-- this current blog follows the recent one on the ineffectiveness of opiates to treat acute low back or neck pain: http://gmodestmedblogs.blogspot.com/2023/08/acute-low-back-or-neck-pain-placebo-was.html . This last blog has many references to prior blogs on opiates, including their overprescription after surgery, their ineffectiveness for chronic back/hip/knee pain, and the equivalency of NSAIDs for dental pain/acute low back pain/kidney stones
-- there is a higher morbidity/mortality from opiates in older people, perhaps related to decreased ability to metabolize them (see opiates elderly dec metab and inc adverse effects ClinIntervAging2008 in dropbox or Chau at al. Clinical Interventions in Aging 2008:3(2)).
-- the elderly may well be at increased risk of specific adverse events: delirium, falls, cognitive impairment, nausea/constipation, bladder dysfunction (see opiate elderly adverse effects BMCgeriatrics2018 in dropbox or 10.1186/s12877-018-0990-1)
-- increased medical problems in the elderly, leading their primary care providers deciding to deal with their urgent issues (heart failure, hypertension, cardiovascular disease, CKD, .......), and not have the time to deal with continued opiate prescriptions in a stable patient who is no longer having pain
-- one of the unfortunate consequences of the structural limitations of primary care in the US: too much to do with patients but too little time (eg, poor reimbursement leading to providers to see too many patients to make ends meet...)
-- ?diversion of opiates to younger people (we have seen a few cases of elder abuse, where younger family members threaten their older relatives if they were not able to get refills on their opiates)
-- and >50% of people who become addicted to opiates do so through pills, often ones left around at home in the medicine cabinet
--this study found that the trajectory of opioid use tracked with dispensing patterns (low use for short periods of time led to much less sustained opiate usage). this has also been found in other studies, though some have found that even short courses in some people can lead to dependence
Limitations:
-- this was not a randomized controlled trial, so one cannot draw clear causal conclusions
-- were those put on transdermal formulations or higher methadone equivalent doses different from those put on lower oral doses? Did they have a stronger indication for more aggressive treatment? did they try the many effective nonpharmacologic and non-opiate pharmacologic approaches to treat chronic or acute pain?
-- there were very limited granular individual data in this study:
-- were those on antidepressants on them because of depression? other indications (chronic pain, sleep...)
-- there was no specific assessment of harm from opiates: was there a dose threshold? were harms different for people in different age groups?
-- as noted above, were there specific numbers or types of comorbidities on an individual level that predisposed people to receiving longer term opioids? were they sicker (as is more likely in the elderly), and their primary care providers too busy dealing with their active medical problems to deal with their opiates (which perhaps were not an immediate concern)?? were older people having more cognitive impairment, and their providers felt that these individuals could not handle multiple simultaneous changes in their medications (and treating their current heart failure etc was the most important issue?)
-- this study did find that there were several predictors for sustained opiate use, but what about combinations? did the elderly individuals who had sustained opiate use try acetaminophen or other meds first? or have depression or psychosis? were the combinations of these "predictors" of sustained opiate use additive? more than additive? less than additive??? there was no enough individual-level granular data in this study to know.
-- the use of buprenorphine as a pain medication may be an issue here: were some of the people put on buprenorphine because of a combo of acute pain and prior opiate addiction. if so, this could potentially distort the study results, since this group would likely be sustained users.
-- this study was based on prescribed opiates, and not actual opiate consumption. at least in the US, studies have shown that dramatically more opiates have been prescribed than used after surgery (and leading to their potential availability to others at home and perhaps their subsequent opioid addiction??): see http://gmodestmedblogs.blogspot.com/2018/01/post-op-surgery-opiates-and-subsequent.html . To draw a conclusion that increased OMEs prescribed is related to subsequent persistent opiate usage really requires information on actual opiate consumption vs written prescriptions
-- and, it would be important to know if some of the individuals not designated as sustained opiate users actually were buying opiates on the street, and actually were in the "sustained" category
so, a few points:
-- this study found that the trajectory of opiate use tracked with dispensing patterns (low use for short periods of time was far superior to the higher use scenarios)
-- it reaffirms that opiate use tends to lead to chronic use in some individuals, especially the elderly.
-- this all amplifies the importance of weaning elderly off the opiates at a rate acceptable to the patient, in order to avoid all of the potential long-term opiate use and its attendant complications.
-- And this really should be a clinical priority for us...
geoff
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