From the AGA Journals

Opioids linked to mortality in IBD

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Does opioid use in IBD result in increased mortality? 

Balancing control of pain and prevention of opioid-related morbidity and mortality remains a major challenge for health care providers, particularly in IBD. This study by Burr et al. highlights the potential dangers of opiate use among patients with IBD with the finding that opioid prescriptions at least three times per year were associated with a two- to threefold increase in mortality. Another important observation from this study was that the prevalence of opioid use among IBD patients increased from 10% to 30% during 1990-2013. One would like to believe that, with better treatment modalities for IBD, fewer patients would require chronic opioid medications over time; however, this observation suggests that there has been a shift in the perception and acceptance of opioids for IBD patients.

Studying opioid use among IBD patients remains challenging as even well-controlled retrospective studies are unable to fully separate whether opioid use is merely associated with more aggressive IBD courses and hence worse outcomes, or whether opioid use directly results in increased mortality. As clinicians, we are left with the difficult balance of addressing true symptoms of pain with the potential harm from opioids; we often counsel against the use of nonsteroidal anti-inflammatory medications in IBD, and yet there is growing concern about use of opioids in this same population. Further research is needed to address patients with pain not directly tied to inflammation or complications of IBD, as well as nonmedical, behavioral approaches to pain management.

Dr. Jason K. Hou

Jason K. Hou, MD, MS, is an investigator in the clinical epidemiology and outcomes program, Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center, Houston; assistant professor, department of medicine, section of gastroenterology & hepatology, Baylor College of Medicine, Houston; and codirector of Inflammatory Bowel Disease Center at the VA Medical Center at Baylor. He has no conflicts of interest.



From 1990 through 1993, only 10% of patients with IBD were prescribed opioids, vs. 30% from 2010 through 2013 (P less than .005). After the investigators controlled for numerous demographic and clinical variables, being prescribed a strong opioid (morphine, oxycodone, fentanyl, buprenorphine, methadone, hydromorphone, or pethidine) more than three times per year significantly correlated with all-cause mortality in both Crohn’s disease (hazard ratio, 2.2; 95% confidence interval, 1.2-4.0) and ulcerative colitis (HR, 3.3; 95% CI, 1.8-6.2), the researchers reported.Among patients with ulcerative colitis, more moderate use of strong opioids (one to three prescriptions annually) also significantly correlated with all-cause mortality (HR, 2.4; 95% CI, 1.2-5.2), as did heavy use of codeine (HR, 1.8; 95% CI, 1.1-3.1), but these associations did not reach statistical significance among patients with Crohn’s disease. Tramadol was not linked to mortality in either IBD subtype when used alone or in combination with codeine.

Dr. Burr and his associates said they could not control for several important potential confounders, including fistulating disease, quality of life, mental illness, substance abuse, and history of abuse, all of which have been linked to opioid use in IBD. Nonetheless, they found dose-dependent correlations with mortality that highlight a need for pharmacovigilance of opioids in IBD, particularly given dramatic increases in prescriptions, they said. These were primary care data, which tend to accurately reflect long-term medication use, they noted.

Crohn’s and Colitis U.K. and the Leeds Teaching Hospitals NHS Trust Charitable Foundation provided funding. The investigators reported having no conflicts of interest.

SOURCE: Burr NE et al. Clin Gastroenterol Hepatol. doi: 10.1016/j.cgh.2017.10.022.

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