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Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients.
Clin J Am Soc Nephrol. 2018 05 07; 13(5):746-753.CJ

Abstract

BACKGROUND AND OBJECTIVES

Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment).

RESULTS

The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture.

CONCLUSIONS

Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.

Authors+Show Affiliations

Departments of Medicine and julie.ishida@ucsf.edu. Division of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; and.Epidemiology and Biostatistics, University of California, San Francisco, California.Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California.Epidemiology and Biostatistics, University of California, San Francisco, California.Departments of Medicine and. Division of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; and. Epidemiology and Biostatistics, University of California, San Francisco, California.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

29674340

Citation

Ishida, Julie H., et al. "Opioid Analgesics and Adverse Outcomes Among Hemodialysis Patients." Clinical Journal of the American Society of Nephrology : CJASN, vol. 13, no. 5, 2018, pp. 746-753.
Ishida JH, McCulloch CE, Steinman MA, et al. Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients. Clin J Am Soc Nephrol. 2018;13(5):746-753.
Ishida, J. H., McCulloch, C. E., Steinman, M. A., Grimes, B. A., & Johansen, K. L. (2018). Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients. Clinical Journal of the American Society of Nephrology : CJASN, 13(5), 746-753. https://doi.org/10.2215/CJN.09910917
Ishida JH, et al. Opioid Analgesics and Adverse Outcomes Among Hemodialysis Patients. Clin J Am Soc Nephrol. 2018 05 7;13(5):746-753. PubMed PMID: 29674340.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients. AU - Ishida,Julie H, AU - McCulloch,Charles E, AU - Steinman,Michael A, AU - Grimes,Barbara A, AU - Johansen,Kirsten L, Y1 - 2018/04/19/ PY - 2017/09/08/received PY - 2018/01/24/accepted PY - 2018/4/21/pubmed PY - 2019/11/14/medline PY - 2018/4/21/entrez KW - Analgesics, Opioid KW - Cohort Studies KW - Emergency Service, Hospital KW - Humans KW - Medicare KW - Middle Aged KW - Morphine KW - Opioid-Related Disorders KW - Pain KW - United States KW - United States Renal Data System KW - clinical epidemiology KW - hemodialysis KW - hospitalization KW - opioid KW - renal dialysis SP - 746 EP - 753 JF - Clinical journal of the American Society of Nephrology : CJASN JO - Clin J Am Soc Nephrol VL - 13 IS - 5 N2 - BACKGROUND AND OBJECTIVES: Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment). RESULTS: The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture. CONCLUSIONS: Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use. SN - 1555-905X UR - https://www.unboundmedicine.com/medline/citation/29674340/Opioid_Analgesics_and_Adverse_Outcomes_among_Hemodialysis_Patients_ L2 - https://cjasn.asnjournals.org/cgi/pmidlookup?view=long&pmid=29674340 DB - PRIME DP - Unbound Medicine ER -