While the dangers of overdose among patients prescribed powerful opioid painkillers such as Oxycontin and fentanyl are well known, a new study found unexpected heart risks with the medications.
Patients who had just been prescribed an opioid painkiller had a 64 percent higher risk of early death when compared to patients who were given an alternative pain medication. But much of that increased risk was related to the onset of breathing difficulties during sleep, followed by heart rhythm irregularities and other cardiovascular complications.
"We were not surprised by the increased risk for overdose deaths, which is well known," noted study author Wayne Ray, from the department of health policy at Vanderbilt University School of Medicine in Nashville, Tennessee.
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"However, the large increase in cardiovascular death risk is a novel finding," Ray said. "[And] it suggests being even more cautious with opioids for patients who are at high cardiovascular risk, such as those who have had a heart attack or have diabetes."
In the study, the team analysed data collected between 1999 and 2012 on nearly 23,000 patients, average age 48, who had just been prescribed a long-acting opioid medication. The researchers compared that to data on an equal number of patients who had been given an alternate pain medication.
The alternate medications included anticonvulsants such as Neurontin (gabapentin), Lyrica (pregabalin) and Tegretol (carbamazepine) and low-dose antidepressants. Anticonvulsants are used to control seizures, bipolar disorder and/or nerve pain.
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During an average tracking period of about four to six months, there were 185 deaths in the opioid group versus 87 deaths in the alternate medication group.
In all, the opioid group was found to face a 64 percent increased risk of death due to any reason, the team found.
Opioids as a last resort
But the opioid patients also faced a 65 percent increased risk of death specifically related to new heart complications, the findings showed.
The study authors concluded that alternate pain medications should be favoured over long-acting opioids whenever possible, particularly for those patients who have a history of heart disease, heart attack or diabetes.
"Our opinion, which is consistent with the recent guidelines from the Centres for Disease Control and Prevention, is that opioids should be used as a last resort," said Ray.
"The best way to decide if the benefits outweigh the risks is through a careful practitioner-patient discussion."
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Dr Joseph Frank is an assistant professor of medicine in the division of general internal medicine at the University of Colorado School of Medicine. He cautioned that while "we have learned a great deal about the risks of opioid medications in recent years, [we] still have a long way to go".
Need for more research
And, he added, "There may be patients for whom the improvement in function due to opioids outweighs the modest risk found in this study, but this balance is often challenging to assess and communicate to patients, particularly in busy primary care settings."
Frank, who is also a general internist at the VA Medical Centre in Denver, agreed that non-opioid pain treatment is preferable when possible.
But since the study focused exclusively on the risks faced by first-time opioid users, he stressed the need for more research to assess the risks faced by those trying to kick a long-term opioid habit, "as this transition can be very difficult, and may actually increase risk of some adverse events for some patients".
Ray and his team published their findings in the Journal of the American Medical Association.