Reactions 1337 - 5 Feb 2011
Safety concerns about opioid useappear warranted
Two studies by Dr Daniel Solomon and colleagues,published simultaneously in Archives of InternalMedicine, investigate the comparative safety of opioidanalgesics in older adults.1,2 The studies suggest that therisks associated with opioid analgesics are "substantial",2and "recent concerns raised about opioid use innonmalignant pain syndromes appear warranted".1
Small numbers needed to harm with opioidsIn a study conducted among older adults with
arthritis, the research team, who were from the Brighamand Womens Hospital in Boston, showed that ofanalgesics opioids are associated with the highest risksof most specific and severe safety events, whilenonselective NSAIDS (nsNSAIDS) are associated withthe lowest risk.1
The team investigated the incidence of adverse eventsbetween propensity-matched cohorts of Medicarebeneficiaries (mean age 80 years) treated with either annsNSAID, a coxib [cyclo-oxygenase 2 inhibitor] or anopioid analgesic, in a comparison that they suggest,"would likely never be made in the setting of arandomized controlled trial."
While the analgesics comparative safety dependedon the particular event studied; coxibs and opioids wereboth associated with a higher relative risk ofcardiovascular events than nsNSAIDS, and opioids wereassociated with a higher risk of fracture.1 The use ofcoxibs was associated with a similar level of fracture riskas the use of nsNSAIDS and a reduced risk of GIbleeding. Compared with NSAIDS, opioids, but notcoxibs, were associated with an increased risk of safetyevents requiring hospitalisation and an increased risk ofall-cause mortality. The authors say that, "by 1 year, thenumbers needed to harm for opioid users were smalland thus clinically relevant." Meanwhile, "althoughnsNSAIDS pose certain risks, these analyses support thesafety of these agents compared with other analgesics."
Elevated CV risk with codeine "surprising"In a similar cohort study, Solomon and colleagues
investigated the incidence of adverse events amongolder adults initiating therapy with various types ofopioid analgesic for the treatment of nonmalignantpain.2 They explain that it is "a commonly held belief thatall opioids are associated with similar risk"; however,their findings showed that, while the risk of GI adverseevents appeared to be similar across groups, tramadoland dextropropoxyphene [propoxyphene] were bothassociated with significantly lower risks of fracturecompared with hydrocodone. Whats more, in a findingwhich the researchers exclaim is "surprising" andrequiring "further validation in other data sets", codeinewas associated with a significantly elevatedcardiovascular risk after 180 days of treatment.
Overall, the researchers conclude that, "causalinference requires experimental designs, but theseresults should prompt caution and further study."2
1. Solomon DH, et al. The comparative safety of analgesics in older adults witharthritis. Archives of Internal Medicine 170: 1968-78, No. 22, 13 Dec 2010.Available from: URL: http://dx.doi.org/10.1001/archinternmed.2010.391.
2. Solomon DH, et al. The comparative safety of opioids for nonmalignant pain inolder adults. Annals of Internal Medicine 170: 1979-1986, No. 22, 27 Dec 2010.
Reactions 5 Feb 2011 No. 13370114-9954/10/1337-0001/$14.95 2010 Adis Data Information BV. All rights reserved