Peripheral arterial disease patients at increased risk for high opioid use

Nathan Itoga

Patients with peripheral arterial disease (PAD) are found to have an increased risk for high opioid use. Nathan Itoga and colleagues from the University of Stanford (Stanford, USA), presented the findings of a recent study analysing data from the 2007–2015 Truven Marketscan database that identified patients with opioid prescriptions and comorbidities, at the Society for Vascular Surgery’s Vascular Annual Meeting (VAM; 20–23 June, Boston, USA).

The number of deaths from prescription opioid pain relievers has continued to increase in recent years, with the “epidemic” affecting both males and females. According to Itoga, this now poses great concern to the USA.

Although the USA is only 5% of the world’s population, the country consumes 99% of available hydrocodone and 85% oxycodone (opioid derivatives). Itoga emphasised that not only are there prescription related deaths, but the majority of new heroin abusers begin with opioids. Furthermore, over the past two years, opioid-related deaths have been linked to a decrease in life expectancy in the country.

Itoga also noted that the current literature indicates a lack of studies surrounding prescribing patterns. One of the goals of Itoga et al’s study was to investigate the effects of peripheral arterial disease on opioid prescription patterns. Additionally, the authors sought to evaluate high opioid users in patients. For these reasons, Itoga stated that providers need to be vigilant in their prescribing patterns.

Using the 2007–2015 Truven Marketscan database, Itoga and colleagues retrospectively identified patients with opioid prescriptions as well as comorbidities. They further investigated the impact of PAD related procedures, including open and endovascular revascularisation procedures as well as amputations above the ankle.

Given that the authors used a de-identified national private insurance claims database, they included patients with ≥ two ICD-9 diagnosis codes of PAD ≥ two months apart with at least two years of continuous enrolment. Critical limb ischaemia (CLI) was defined as rest pain, ulcers or gangrene. The primary outcome was high opioid use, defined as ≥ two opioid prescriptions within a one-year period. Opioid prescriptions were excluded if filled within 90 days of a PAD-related procedure, identified by CPT codes for lower extremity open and endovascular revascularisation or amputation.

A total of 182,186 patients with PAD met the inclusion criteria, 27.1% of whom had CLI. An average of 24.4% of patients with PAD met the high opioid use criteria in any given calendar year, with a decreasing trend for patients meeting criteria beginning in 2010 (p<0.01). Of high opioid users, 26% continued to meet criteria for five years.

High opioid use was more common for patients with CLI (32.2% vs. 21.4%, p<0.01). During years of high opioid use 5.9±5.3 yearly prescriptions were filled. The multivariate analysis indicated that illicit drug use and back pain were the strongest predictors of high opioid use (p<0.001).

Additionally, a new diagnosis of PAD increased high opioid use (21.3% before PAD diagnosis vs. 26.9% after PAD diagnosis, p<0.01). This association was seen for patients without CLI (20.2% to 24.1%, p<0.01) and with CLI (27.5% to 37.7%, p<0.01).

PAD treatment—after excluding peri-procedural opioid prescriptions—was found to increase high opioid use percentage, even after excluding 90-day related prescriptions—as the percentage increased from 25.6% pre-treatment to 29.2% post-treatment (p<0.01).

Itoga noted limitations of the retrospective study. As the authors derived data from a claims database, it would have been prone to residual confounding. Limited information regarding physician practices as well as the private insurance aspect of the sample also reduced the validity; with the latter limiting generalisability to patients above the age of 65.

Irrespective of the current limitations, Itoga concluded that patients with PAD are at increased risk for high opioid use, with nearly one-quarter meeting described criteria. CLI additionally increases opioid utilisation, but PAD treatment does not appear to decrease high opioid use. In relation to moving forward, Itoga said that in addition to heightened awareness and active opioid management, the findings warrant further investigation into causes and deterrence of high-risk opioid use, and further reiterated that providers in particular should be aware of those diagnoses when prescribing opioids to patients.


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