Increasing Prescription of Opiates and Mortality in Patients With Inflammatory Bowel Diseases in England

Burr, Nicholas; Smith, Chris; West, Robert; Hull, Mark A.; Subramanian, Venkataraman

doi:10.1016/j.cgh.2017.10.022

Cited by 78 publications

(57 citation statements)

References 33 publications

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“…11 Another study failed to show a statistically significant mortality difference between prescription of tramadol alone or in combination with codeine compared with infrequent or no prescription of tramadol alone or combined with codeine among 8866 patients with Crohn disease and ulcerative colitis. 12 In a large propensity score-matched cohort study that examined the safety of 5 commonly prescribed opioids among 31 375 Medicare beneficiaries in the United States, initial prescription of tramadol was not associated with a statistically significant Abbreviations: COX-2, cyclooxygenase 2; HR, hazard ratio; NSAIDs, nonsteroidal anti-inflammatory drugs; OA, osteoarthritis; PS, propensity score; RD, rate difference. a Asymmetric trimming was used to exclude participants whose propensity score was below the 2.5th percentile of the propensity score of the tramadol cohort and above the 97.5th percentile of the propensity-score of the comparator cohort.…”

Section: Discussionmentioning

confidence: 99%

“…7 Few studies have examined the relationship between tramadol prescription and all-cause mortality, and current evidence regarding the association of tramadol with mortality rates compared with other analgesic medications is inconclusive. [8][9][10][11][12][13] The present study examined the association of initial prescription of tramadol with all-cause mortality compared with alternative commonly prescribed analgesics in patients with osteoarthritis.…”

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confidence: 99%

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Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis

Zeng

Dubreuil

Larochelle

et al. 2019

JAMA

167

187

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Surgeons guideline recommends tramadol for patients with knee osteoarthritis, and an American College of Rheumatology guideline conditionally recommends tramadol as first-line therapy for patients with knee osteoarthritis, along with nonsteroidal anti-inflammatory drugs.OBJECTIVE To examine the association of tramadol prescription with all-cause mortality among patients with osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS Sequential, propensity score-matched cohort study at a general practice in the United Kingdom. Individuals aged at least 50 years with a diagnosis of osteoarthritis in the Health Improvement Network database from January 2000 to December 2015, with follow-up to December 2016. EXPOSURES Initial prescription of tramadol (n = 44 451), naproxen (n = 12 397), diclofenac (n = 6512), celecoxib (n = 5674), etoricoxib (n = 2946), or codeine (n = 16 922). MAIN OUTCOMES AND MEASURES All-cause mortality within 1 year after initial tramadol prescription, compared with 5 other pain relief medications. RESULTS After propensity score matching, 88 902 patients were included (mean [SD] age, 70.1 [9.5] years; 61.2% were women). During the 1-year follow-up, 278 deaths (23.5/1000 person-years) occurred in the tramadol cohort and 164 (13.8/1000 person-years) occurred in the naproxen cohort (rate difference, 9.7 deaths/1000 person-years [95% CI, 6.3-13.2]; hazard ratio [HR], 1.71 [95% CI, 1.41-2.07]), and mortality was higher for tramadol compared with diclofenac (36.2/1000 vs 19.2/1000 person-years; HR, 1.88 [95% CI, 1.51-2.35]).Tramadol was also associated with a higher all-cause mortality rate compared with celecoxib (31.2/1000 vs 18.4/1000 person-years; HR, 1.70 [95% CI, 1.33-2.17]) and etoricoxib (25.7/1000 vs 12.8/1000 person-years; HR, 2.04 [95% CI, 1.37-3.03]). No statistically significant difference in all-cause mortality was observed between tramadol and codeine (32.2/1000 vs 34.6/1000 person-years; HR, 0.94 [95% CI, 0.83-1.05]).CONCLUSIONS AND RELEVANCE Among patients aged 50 years and older with osteoarthritis, initial prescription of tramadol was associated with a significantly higher rate of mortality over 1 year of follow-up compared with commonly prescribed nonsteroidal anti-inflammatory drugs, but not compared with codeine. However, these findings may be susceptible to confounding by indication, and further research is needed to determine if this association is causal.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis

Zeng

Dubreuil

Larochelle

et al. 2019

JAMA

167

187

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“…As evidenced above, hypoalgesic IBD patients demonstrate significantly better quality of life scores than their symptomatic counterparts with active disease, and exhibit symptom profiles that are similar to their quiescent counterparts. Although there are clearly consequences to the lack of appropriate symptomatology in the setting of IBD, conditions defined more by the presence of symptoms such as abdominal pain rather than an overt inflammatory process, including irritable bowel syndrome (IBS), might benefit from alternative approaches to pain management, particularly when we consider the lack of efficacy and/or toxicity of the available analgesics frequently utilized to manage disorders associated with chronic abdominal pain, including NSAIDs and opiates [26][27][28][29]. Notably, our study demonstrated an independent association between hypoalgesic IBD and mesalamine.…”

Section: Discussionmentioning

confidence: 99%

Gastrointestinal hypoalgesia in inflammatory bowel disease

Coates¹,

Soriano²,

Dalessio³

et al. 2019

aog

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Background Pain perception is critical for detection of noxious bodily insults. Gastrointestinal hypoalgesia in inflammatory bowel disease (IBD) is a poorly understood phenomenon previously linked to poor patient outcomes. We aimed to evaluate the risk factors associated with this condition and to discern characteristics that might differentiate these patients from pain-free quiescent counterparts. Methods We performed a retrospective analysis using an IBD natural history registry based in a single tertiary care referral center. We compared demographic and clinical features in 3 patient cohorts defined using data from simultaneous pain surveys and ileocolonoscopy: a) active IBD without pain (hypoalgesic IBD); b) active IBD with pain; and c) inactive IBD without pain. Results One hundred fifty-three IBD patients had active disease and 43 (28.1%) exhibited hypoalgesia. Hypoalgesic IBD patients were more likely to develop non-perianal fistulae (P=0.03). On logistic regression analysis, hypoalgesic IBD was independently associated with male sex, advancing age and mesalamine use, and inversely associated with anxious/depressed state and opiate use. Hypoalgesic IBD patients were demographically and clinically similar to the painfree quiescent IBD cohort (n=59). Platelet count and C-reactive protein were more likely to be pathologically elevated in hypoalgesic IBD (P=0.03), though >25% did not exhibit elevated inflammatory markers. Conclusions Hypoalgesia is common in IBD, particularly in male and older individuals, and is associated with an increased incidence of fistulae and corticosteroid use. Novel noninvasive diagnostic tools are needed to screen for this population, as inflammatory markers are not always elevated.

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“…Generally, use of pain medication was viewed negatively, be this due to apprehension over side effects or associated longterm risks with stronger pain medication. Opioid dependence is becoming an increasingly recognised issue in IBD, with prevalence rates rising in England (29) and the USA (30). Ample evidence now demonstrates the clinical characteristics and associated risks of long-term opioid use, including psychiatric diagnosis, hospitalisation and development of narcotic bowel syndrome (31,32).…”

Section: Discussionmentioning

confidence: 99%

‘It’s about willpower in the end. You’ve got to keep going’: a qualitative study exploring the experience of pain in inflammatory bowel disease

Sweeney

Moss‐Morris

Czuber‐Dochan

et al. 2019

British Journal of Pain

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Background: Pain is a widely experienced symptom of inflammatory bowel disease (IBD), which has significant psychological and functional impacts on patients. Understanding the aetiology and management of chronic pain is a poorly understood area of IBD research. This qualitative study aimed to explore the experiences of individuals with IBD and pain, the pain management strategies they use and any needs for future pain management interventions. Methods: In all, 14 individuals with IBD were purposively recruited and interviewed (face-to-face or telephone) using a topic guide. Interviews were transcribed and analysed using inductive thematic analysis. Results: Themes identified were ‘vicious cycles’, ‘findings solutions’ and ‘attitudes’. The experience and impact of pain were rarely viewed in isolation, but rather within the context of a cycle of IBD symptoms. Other ‘vicious cycles’ identified included anxiety, avoidance and inactivity, and poor understanding and communication. Pain management included short- and long-term strategies. Searching for a solution for pain had an emotional impact on individuals. There were contrasting attitudes from participants, including defeat, tolerance and acceptance. Conclusion: This study provides an understanding of the experience of pain in IBD. The interaction of pain with accompanying IBD symptoms has an emotional and physical impact on individuals, and creates a barrier to adequate assessment, understanding and treatment of pain. Patients rely on their own experiences, and a trial and error approach to apply helpful strategies. Adjuvant behavioural therapies may be beneficial for patients experiencing pain and psychological distress, and to facilitate self-management.

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Increasing Prescription of Opiates and Mortality in Patients With Inflammatory Bowel Diseases in England

Abstract: In an analysis of primary care patients with IBD in England, we found prescriptions for opiate drugs to have increased significantly from 1990 through 2013. Heavy use of strong opiates among patients with IBD associates with increased all-cause premature mortality.

Cited by 78 publications

References 33 publications

Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis

Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis

Gastrointestinal hypoalgesia in inflammatory bowel disease

‘It’s about willpower in the end. You’ve got to keep going’: a qualitative study exploring the experience of pain in inflammatory bowel disease

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