Bibliographic reference
Herzig SJ, Anderson TS, Jung Y, Ngo LH, McCarthy EP. Risk factors for opioid-related adverse drug events among older adults after hospital discharge. J Am Geriatr Soc. 2021 Sep 15. doi: 10.1111/jgs.17453. Epub ahead of print. PMID: 34528242.
At a glance
Opioids are a major cause of drug-related side effects during hospitalization and immediately after hospital discharge. In this large cohort of older adults, a potential opioid-related adverse drug event (ADE) occurred in 7% of those discharged with an opioid prescription. Gastrointestinal issues and delirium were the most common potential opioid-related ADEs. The authors also identified numerous risk factors, the strongest of which were: the presence of dementia or delirium, the presence of red flags for opioid misuse, and the prescription of long-acting opioids.
The context
It is already known that, regardless of age, opioids are one of the major causes of ADEs during hospitalization or shortly after discharge. Their prescription is quite common during hospital stay and these drugs are frequently prescribed to older patients who have never previously taken them. Patients older than 65 are at a higher risk of ADEs for multiple reasons (comorbidities, polytherapies, changes in pharmacodynamics and pharmacokinetics). In this study, the authors aimed at evaluating the incidence and potential risk factors for opioid-related ADEs, in the specific context of the elderly population.
Characteristics of the study
This is a large cohort study, in which the authors collected data from administrative databases (Medicare) on subjects older than 65 years who were hospitalized in 2016. Patients discharged to a facility or with a diagnosis of cancer were not included. The study evaluated the incidence of potential opioid-related ADEs within 30 days from hospital discharge. The definition of ADEs included:
- An unplanned visit to the Emergency Room
- A hospitalization with a diagnosis code for any of the following known opioid-related adverse events (constipation, delirium, nausea/vomiting, fall/fracture, urinary retention, poisoning from opioids.
The authors also aimed to identify potential risk factors for ADE. Along with collecting clinical and demographic data, they evaluated the presence of “red flags” (for example, an average daily dose of morphine greater than 120 mg for any 90-day period, and a prescription for opioids from four or more prescribers during year before hospital admission).
Results
The authors analyzed the data of 299,239 hospitalized patients; 22,879 (7.6%) of them requested an opioid prescription within two days after hospital discharge. 1,604 patients (7%) experienced a potential opioid-related ADE within 30 days from hospital discharge and another 1,091 (4,8%) within 14 days. The majority of potential opioid-related ADEs were identified during hospitalization (1134; 70.7%), while 470 (29.3%) were identified during an ER visit without hospitalization. The most common potential opioid-related ADEs were slowed colonic motility (2.7%), delirium (1.8%) and nausea/vomiting (1.5%). The authors identified several characteristics associated with a potential opioid-related ADE, including age of 80 years or older, kidney disease, dementia/delirium, anxiety disorder, opioid use disorder, intestinal and pancreaticobiliary disorders, musculoskeletal and nervous system injuries, “red flags” for opioid misuse, and prescription of long-acting opioids. Similar results were seen when considering only the first 14 days after hospital discharge, with the addition of female gender being found as a significant predictive factor.
Limits of the study
The main limitations of this study relate to the general design, based on the use administrative data. First, reliance on billing codes could have resulted in the underestimation of potential opioid-related ADEs. Second, the design did not make it possible to reliably confirm the causal relationship between the ADEs and opioid use, which is why the authors speak more generally of “potential” opioid-related ADEs.
What is new?
Previous studies have already evaluated the risk factors for opioid-related ADEs in patients both in the hospital and in outpatient settings. This study was the first to focus on older adults in the immediate period after discharge from a hospital stay that resulted in an opioid prescription.
Perspectives
The results of the present study should discourage the use of long-acting opioids in the elderly. Moreover, the increasing awareness by healthcare personnel of risk factors for potential opioid-related ADEs may contribute to a more tailored treatment of the elderly, with a view to developing strategies that reduce the risk of adverse events.
Edited by Davide Di Benedetto
