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Pattern of Opioid Analgesic Use among Patients with End-stage Renal Disease

 
According to the authors of a recent study, almost 50% of patients with end-stage renal disease (ESRD) say they have chronic pain, and over 75% of them rate it as being moderate to severe. The various causes of pain arise from other current illnesses, renal osteodystrophy, and complications of the dialysis procedure.
 
Anne Mobley Butler, Doctoral Candidate in Epidemiology at Gillings School of Global Public Health of the University of North Carolina at Chapel Hill, and colleagues reported their findings at Kidney Week 2013, the American Society of Nephrology's annual meeting in Atlanta, GA, on November 9, 2013.
 
They found that almost half of dialysis patients reported chronic pain, that 83% rated it as being moderate to severe, and that it was often related to other conditions, including peripheral vascular disease and osteoarthritis, complications of kidney failure such as peripheral neuropathy, osteodystrophy and calciphylaxis, as well as to factors related to the dialysis procedure itself, such as needling, dialysate infusion, and osmolar shift.
 
Because non-steroidal anti-inflammatory drugs (NSAIDS) have adverse effects on renal function, opioids may be the preferred analgesic agents among these patients and little is known about patterns of opioid use and the safety and effectiveness of opioids in patients receiving dialysis. The authors’ research aimed to quantify the magnitude of opioid use among ESRD patients in the US.
 
The researchers gathered data from the United States Renal Data System (USRDS) national registry of patients in the Medicare ESRD program and identified patients 18 years of age and older who received dialysis on January 1, 2008 with Medicare as their primary payer and parts A, B, and D coverage. They obtained information on opioid from the Medicare part D claims and calculated the proportion of patients receiving opioid prescriptions. Patients were followed until the end of continuous enrollment in Medicare Parts A, B, and D; loss-to-follow-up; kidney transplant; death; or end of study on June 30, 2008.
 
They found that during the 6-month study period, 335,888 opioid prescriptions were written. Of the 156,476 eligible dialysis patients, 77,697 (50%) patients used an opioid, with hydrocodone, oxycodone, and propoxyphene prescribed to 30%, 14%, and 10% of the patients, respectively. The mean age of the patients was 60 years; 52% of patients were male, 50% were white, 43% were black, and 8% were low-income subsidy (LIS) status. Opioid use was higher among younger patients, females and those without low income subsidy status, and varied according to the primary cause of ESRD, the number of years on dialysis, and the type of dialysis. In a separate analysis with similar eligibility criteria, quarterly opioid use increased slightly from the third quarter of 2006 (38%) to the fourth quarter of 2008 (39%).
 
Having investigated widespread and increasing use of opioids among ESRD patients in the United States, the authors urge that, in step with increasing concerns about opioid safety in the elderly, more research be carried out to better understand the safety and effectiveness of opioids in ESRD patients.

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More Reading
Citing a “public health epidemic” of death and addiction related to use of prescription opioids, the American Academy of Neurology (AAN) calls for a multi-pronged approach to curbing prescriptions. But the group stresses that finding ways to help patients in chronic pain is worthwhile and difficult.