All opioids are not created equal, in terms of safety
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All opioids are not created equal, in terms of safety A US-based study published in Archives of Internal Medicine found that opioid analgesics commonly used among older adults for noncancer pain carry very different risks.1 The authors say that these risks are "substantial and translated into numbers needed to treat that would be considered clinically significant". They constructed a propensity-matched cohort analysis using data for US Medicare beneficiaries who were new initiators of opioid therapy for nonmalignant pain. Five groups of 6275 subjects (mean age 79 years) each were gathered according to the opioid used: codeine; hydrocodone; oxycodone; propoxyphene; and tramadol. At 30 days after opioid initiation, the risk of cardiovascular events was similar across the groups, but was elevated for codeine after 180 days (RR 1.62; 95% CI 1.27, 2.06). Another notable finding was that the risk of fracture was significantly reduced for tramadol (0.21; 0.16, 0.28) and propoxyphene (0.54; 0.44, 0.66) versus hydrocodone at 30 days. The analysis also found that allcause mortality was elevated after 30 days’ exposure for oxycodone (2.43; 1.47, 4.00) and codeine (2.05; 1.22, 3.45), compared with hydrocodone. The researchers comment that the observed risks "were not explained by the dosage being prescribed and did not vary across a range of sensitivity analyses".
Conventional notion of safety challenged In an invited commentary, Drs William C Becker and Patrick G O’Connor from Yale University School of Medicine, New Haven, Connecticut, US, say these data show that opioid analgesics "are not necessarily safer than nonopioid analgesics in the elderly in terms of their potential cardiovascular and gastrointestinal side effects and may significantly increase the risk of fracture".2 Moreover, they point out that the study’s findings "challenge the conventional notion that the safety profiles of opioids are generally interchangeable". These data also remind us that many questions about maximising the safety and efficacy of opioids in clinical practice "remain unanswered", they conclude. 1. Solomon DH, et al. The comparative safety of opioids for nonmalignant pain in older adults. Archives of Internal Medicine 170: 1979-86, No. 22, 13 Dec 2010. Available from: URL: http://dx.doi.org/10.1001/archinternmed.2010.450. 2. Becker WC, et al. The safety of opioid analgesics in the elderly: new data raise new concerns:comment on "the comparative safety of opioids for nonmalignant pain in olderadults". Archives of Internal Medicine 170: 1986-8, No. 22, 13 Dec 2010. Available from: URL: http://dx.doi.org/10.1001/archinternmed.2010.443. 801108849
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Reactions 22 Jan 2011 No. 1335
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