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Opioid use tied to pneumococcal disease risk

Roshini Claire Anthony
09 Mar 2018

Individuals using opioid analgesics may be at an elevated risk of invasive pneumococcal disease, particularly those using long-acting, high-potency, immunosuppressive, or high-dose opioids, results of a nested case-control study show.

“The association between opioid use and the risk of invasive pneumococcal diseases was strongest for opioids used at high doses, those classified as high-potency and long-acting, which would be the extended-release or controlled-release formulations,” said study lead author Dr Andrew Wiese from the Department of Health Policy at Vanderbilt University School of Medicine, Nashville, Tennessee, US, highlighting that healthcare providers should keep these findings in mind when deciding on pain management for their patients.

Using data on oral or transdermal opioid prescription refills from 1995 to 2014 from the Tennessee Medicaid database, researchers identified 1,233 patients aged ≥5 years with laboratory-confirmed invasive pneumococcal disease (case group) and compared them with 24,399 age-, diagnosis date-, and county of residence-matched controls (control group). Of these, 25.2 percent of case patients were current opioid users compared with 14.4 percent of patients in the control group.

Individuals currently on opioids were more likely to have invasive pneumococcal disease than patients with remote opioid use (no opioid prescription ending 182 days prior to index date; adjusted odds ratio [adjOR], 1.62, 95 percent confidence interval [CI], 1.36–1.92). [Ann Intern Med 2018;doi:10.7326/M17-1907]

The association was particularly strong with the use of long-acting (adjOR, 1.87, 95 percent CI, 1.24–2.82) or high-potency opioids (adjOR, 1.72, 95 percent CI, 1.32–2.25), or with the use of opioids at high doses (adjOR, 1.71 and 1.75 for 50–90 and ≥90 morphine milligram equivalents per day, respectively).

The elevated risk with current opioid use was also present regardless of whether disease pertained to pneumonia or non-pneumonia invasive pneumococcal disease (adjOR, 1.54 and 1.94, respectively).

“Previous studies conducted in animal models had demonstrated that certain opioids can cause immunosuppression and render experimental animals susceptible to infections. However, the clinical implications of those observations in humans were unclear,” said senior study author Associate Professor Carlos Grijalva, also from Vanderbilt University.

The researchers acknowledged that as opioid use was based on prescription refills, actual use could not be determined, nor could “illicit opioid use”. They also suggested the association between opioids and pneumococcal disease may vary by type of opioid due to  differing bioavailability, half-life, and number of active metabolites, a hypothesis that requires testing in future studies.

“We need randomized trials and controlled observational studies in patients receiving postoperative prescriptions for short-acting opioids with and without immunosuppressive properties,” said Drs Sascha Dublin and Michael Von Korff from the Kaiser Permanente Washington Health Research Institute, Seattle, Washington, US, in an editorial. [Ann Intern Med 2018;doi:10.7326/M18-0001]

“While awaiting more definitive answers, we must reconsider the risks and benefits of opioids. Opioid prescribing should be consistently cautious and closely monitored among all patients, especially those at increased risk for infections, who may be particularly susceptible to harm. Cautious prescribing should not be limited to patients deemed at increased risk for drug addiction or overdose,” they said.

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