Magazine article Clinical Psychiatry News

Opioid Safety Varies in Elderly with Nonmalignant Pain

Magazine article Clinical Psychiatry News

Opioid Safety Varies in Elderly with Nonmalignant Pain

Article excerpt

The risks of opioid use for elderly patients with nonmalignant pain vary considerably by different agents and by different durations of use, said Dr. Daniel H. Solomon and his associates in the rheumatology department and the pharmacoepidemiology division at Brigham and Women's Hospital, Boston.

Patients taking codeine for more than 180 days are at increased risk for cardiovascular events, and those taking oxycodone or codeine for only 30 days are at increased risk for mortality due to any cause. "This study's findings do not agree with a commonly held belief that all opioids are associated with similar risk," the investigators noted.

They compared the safety profiles of different opioids for the treatment of nonmalignant pain in elderly patients because "relatively little attention has been paid" to this issue even though the use of these drugs has increased by 50%-100% in recent years.

Dr. Solomon and his colleagues analyzed information in two states' Medicare databases of pharmaceutical coverage for low-income patients (mean age, 79 years) between 1995 and 2005. They were able to match 6,275 subjects who took five of the most commonly prescribed opioids for a variety of baseline factors using propensity scores.

Hydrocodone was used as the reference exposure, to which codeine, oxycodone, propoxyphene, and tramadol were compared.

The risk of cardiovascular events including MI, stroke, heart failure, revascularization, and cardiac death was similar across the five opioid groups after 30 days of use. However, by 180 days the cardiovascular risk with codeine was significantly elevated (risk ratio, 1.62), compared with the other four opioids.

This surprising finding requires validation in other populations, the investigators said (Arch. Intern. Med. 2010;170:1979-86).

All-cause mortality was elevated after only 30 days of use for patients taking oxycodone (RR, 2.43) or codeine (RR, 2.05), but not for those taking other opioids.

In contrast, the risk of fracture of the hip, pelvis, wrist, or humerus was significantly reduced after 30 days of treatment for patients taking tramadol (RR, 0.21) or propoxyphene (RR, 0.54).

The risk of gastrointestinal adverse events--which included upper GI bleeding, lower GI bleeding, and bowel obstruction--did not differ across opioid groups at either 30 days or 180 days.

Importantly the risks were consistent regardless of whether patients were taking low, medium, high, or very high doses of the drugs, Dr. …

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