March 20, 2018
By Will Boggs MD
NEW YORK (Reuters Health) - Prescription opioid analgesic use is associated with a significantly increased risk for invasive pneumococcal diseases (IPDs), researchers report.
"One of the more interesting results was that opioid use was significantly associated with both pneumonia and non-pneumonia invasive pneumococcal disease, indicating that the association cannot be fully attributed to opioid-related respiratory depression and aspiration, but instead this aligns with previous observations from animal models that indicate that certain opioids may indeed increase the susceptibility to serious infections,” Dr. Andrew D. Wiese from Vanderbilt University Medical Center, Nashville, Tennessee, told Reuters Health by email.
In animal models, opioids reduce immune cell activity and lead to increased susceptibility to bacterial infections, including those caused by Streptococcus pneumoniae. It remains unclear whether opioids have similar effects in humans.
Dr. Wiese's team investigated whether opioid analgesic use is an independent risk factor for IPD in a retrospective study of 1,233 patients with laboratory-confirmed IPD and 24,399 matched controls from the managed Medicaid program in Tennessee.
Current use of opioids was associated with a 62% increased risk for IPD, compared with remote opioid use, after adjustment for other IPD risk factors, according to the February 12 Annals of Internal Medicine online report.
The risk was higher with long-acting opioids (87% increased risk) than with short-acting opioids (58% increased risk), and the risk was similar across all daily opioid dose categories.
The IPD risk was highest for high-potency opioids and opioids with previously described immunosuppressive properties (e.g., codeine, morphine, fentanyl, and methadone).
The association between current opioid use and IPD was significant for both pneumonia (54% increased risk) and non-pneumonia IPD (94% increased risk).
“Providers should consider these findings when choosing whether to treat with opioid analgesics in the first place and also when considering the type of opioid formulation to prescribe, especially among individuals already at high-risk for infections, such as older adults,” Dr. Wiese said.
Providers should also consider this information when formulating strategies to prevent IPD, including vaccination, he said.
Dr. Sascha Dublin from Kaiser Permanente Washington Health Research Institute and University of Washington, Seattle, who coauthored a related editorial, told Reuters Health by email, “Opioids might cause serious infections - so we need to be cautious in using them with vulnerable patients, such as those with immunosuppressive illnesses or medications. We need to consider the risk of infection when we weigh the risks vs. benefits of prescribing an opioid to a patient. We urgently need more research to figure out which opioids are the safest for patients at particularly high infection risk - such as postoperative patients or those on other immunosuppressive medications.”
“Include this in the list of possible risks you discuss with patients and do shared decision making - make sure your patients are fully informed about the likelihood of benefit, and the risks they will be taking,” she said. “For patients with chronic pain who start an opioid, it is reasonable to expect pain to go down by maybe 1/3 in severity - it will probably not go down to 0. If patients understand the moderate benefits and the considerable risks, some will choose not to take an opioid.”
Dr. Jose Luis Bonilla from FEA Anestesiologia y Reanimacion, Complejo Hospitalario Universitario de Huelva, in Spain, recently reviewed opioids and immunosuppression in oncological postoperative patients. He told Reuters Health by email, "The increased risk of IPD associated with the use of opioids should lead to an adjustment of opioid treatment using those whose potency is sufficient to control pain, without using opioids with greater potency or at high doses when it is not necessary.”
“It would be interesting to analyze in an individualized study the role of each opioid and its association with the IPD risk,” he said.
SOURCES: http://bit.ly/2Cf21Qa and http://bit.ly/2H9wumd
Ann Intern Med 2018.
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