Hemodialysis patients: Opioids increase mortality, dialysis discontinuation and hospitalization
The conundrum: Patients with end-stage renal disease (ESRD) should receive aggressive pain treatment – but the prescription of opioids to these patients should be “cautiously” handled, according to new Centers for Disease Control and Prevention guidelines.
To complicate matters further, not enough is currently known about the outcomes of ESRD patients receiving opioids, state nephrologists at the National Institutes of Health in Bethesda, MD (USA) (Kimmel PL et al, Opioid Prescription, Morbidity, and Mortality in United States Dialysis Patients. J Am Soc Nephrol. 2017;28:3658-3670.). The nephrologists used data from 153,758 hemodialysis (HD) patients (the 2006 - 2010 cohort of the US Renal Data System) to assess associations between opioid prescription / dose and patient outcomes.
The main results:
More than 60% of dialysis patients had at least one opioid prescription each year.
Around 20% of patients had a chronic (≥ 90-day supply) opioid prescription each year, most commonly for hydrocodone, oxycodone, or tramadol.
Compared with patients without an opioid prescription, patients with short-term (1-89 days) as well as chronic opioid prescriptions had increased mortality, dialysis discontinuation, and hospitalization.
All opioid drugs were associated with mortality; the majority of these drugs were associated with worsened morbidity.
Higher opioid doses correlated with death in a “monotonically increasing fashion”.
Physicians treating HD patients should be aware that opioid drug prescription is associated with increased risk of death, dialysis discontinuation, and hospitalization, warn the authors. Efforts to try and square the circle, i.e. to treat pain effectively in HD patients whilst decreasing opioid prescriptions and dose, should be the subject of further investigations.