Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain.
OBJECTIVE
Long-acting opioids increase the risk of unintentional overdose deaths but also may increase mortality from cardiorespiratory and other causes.


OBJECTIVE
To compare all-cause mortality for patients with chronic noncancer pain who were prescribed either long-acting opioids or alternative medications for moderate to severe chronic pain.


METHODS
Retrospective cohort study between 1999 and 2012 of Tennessee Medicaid patients with chronic noncancer pain and no evidence of palliative or end-of-life care.


METHODS
Propensity score-matched new episodes of prescribed therapy for long-acting opioids or either analgesic anticonvulsants or low-dose cyclic antidepressants (control medications).


METHODS
Total and cause-specific mortality as determined from death certificates. Adjusted hazard ratios (HRs) and risk differences (difference in incidence of death) were calculated for long-acting opioid therapy vs control medication.


RESULTS
There were 22,912 new episodes of prescribed therapy for both long-acting opioids and control medications (mean [SD] age, 48 [11] years; 60% women). The long-acting opioid group was followed up for a mean 176 days and had 185 deaths and the control treatment group was followed up for a mean 128 days and had 87 deaths. The HR for total mortality was 1.64 (95% CI, 1.26-2.12) with a risk difference of 68.5 excess deaths (95% CI, 28.2-120.7) per 10,000 person-years. Increased risk was due to out-of-hospital deaths (154 long-acting opioid, 60 control deaths; HR, 1.90; 95% CI, 1.40-2.58; risk difference, 67.1; 95% CI, 30.1-117.3) excess deaths per 10,000 person-years. For out-of-hospital deaths other than unintentional overdose (120 long-acting opioid, 53 control deaths), the HR was 1.72 (95% CI, 1.24-2.39) with a risk difference of 47.4 excess deaths (95% CI, 15.7-91.4) per 10,000 person-years. The HR for cardiovascular deaths (79 long-acting opioid, 36 control deaths) was 1.65 (95% CI, 1.10-2.46) with a risk difference of 28.9 excess deaths (95% CI, 4.6-65.3) per 10,000 person-years. The HR during the first 30 days of therapy (53 long-acting opioid, 13 control deaths) was 4.16 (95% CI, 2.27-7.63) with a risk difference of 200 excess deaths (95% CI, 80-420) per 10,000 person-years.


CONCLUSIONS
Prescription of long-acting opioids for chronic noncancer pain, compared with anticonvulsants or cyclic antidepressants, was associated with a significantly increased risk of all-cause mortality, including deaths from causes other than overdose, with a modest absolute risk difference. These findings should be considered when evaluating harms and benefits of treatment.
Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee.
Wayne A
WA
Ray
Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
Cecilia P
CP
Chung
Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee3Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee.
Katherine T
KT
Murray
Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee.
Kathi
K
Hall
Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee3Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee.
C Michael
CM
Stein
D000701:Analgesics, Opioid / Q000009:adverse effects* / Q000627:therapeutic use; D000927:Anticonvulsants / Q000627:therapeutic use; D000928:Antidepressive Agents / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000401:mortality; D002423:Cause of Death; D059350:Chronic Pain / Q000188:drug therapy* / Q000401:mortality*; D062787:Drug Overdose / Q000401:mortality; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D005260:Female; D005283:Fentanyl / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008691:Methadone / Q000009:adverse effects / Q000627:therapeutic use; D008875:Middle Aged; D009020:Morphine / Q000009:adverse effects / Q000627:therapeutic use; D010098:Oxycodone / Q000009:adverse effects / Q000627:therapeutic use; D057216:Propensity Score; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012306:Risk
D000701:Analgesics, Opioid; D000927:Anticonvulsants; D000928:Antidepressive Agents; D009020:Morphine; D010098:Oxycodone; D008691:Methadone; D005283:Fentanyl