Opiate toxicity in patients with renal failure

Analgesic use and associated adverse events in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Treating pain in the context of chronic kidney disease (CKD) is challenging because of altered pharmacokinetics and pharmacodynamics, with an increased risk of toxicity and drug adverse events in this population. The aims of this systematic review and meta-analysis were to assess the prevalence of analgesic use and establish the risk of analgesics-related adverse events, in patients with CKD.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Medline, Embase, CINAHL, and CENTRAL were searched until January 2021. Random-effects meta-analyses and meta-regression were conducted to pool and summarise prevalence data and measures of association between analgesic use and adverse events.

RESULTS

Sixty-two studies relevant to the prevalence of analgesic use and 33 to analgesic-related adverse events were included, combining data on 2.3 and 3 million individuals, respectively. Pooled analyses found that 41% (95% confidence interval [CI], 35-48) of the CKD population regularly use analgesia. The annual period prevalence was estimated at 50% for opioids and 21% for nonsteroidal anti-inflammatory drugs (NSAID). Overall, 20% and 7% of patients with CKD are on chronic opioid or NSAID therapy, respectively. Opioid use was associated with an increased risk of death (1.61; 95% CI, 1.12-2.31; n= 7, I²= 91%), hospitalisation (1.38; 95% CI, 1.32-1.45; n=2, I²=0%), and fractures (1.51; 95% CI, 1.16-1.96; n=3, I²=54%).

CONCLUSION

High levels of analgesic consumption and related serious adverse outcomes were found in patients with CKD. Consideration needs to be given to how these patients are assessed and managed in order to minimise harms and improve outcomes.

CLINICAL TRIAL REGISTRATION

CRD42019156491 (PROSPERO).

Association of Opioids and Nonsteroidal Anti-inflammatory Drugs With Outcomes in CKD: Findings From the CRIC (Chronic Renal Insufficiency Cohort) Study

RATIONALE & OBJECTIVE

Safe analgesic choices are limited in chronic kidney disease (CKD). We conducted a comparative analysis of harm from opioids versus nonsteroidal anti-inflammatory drugs (NSAIDs) in CKD.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

3,939 patients with CKD in the Chronic Renal Insufficiency Cohort (CRIC) Study.

EXPOSURES

30-day analgesic use reported at annual visits.

OUTCOMES

A composite outcome of 50% glomerular filtration rate reduction and kidney failure requiring kidney replacement therapy (KRT), as well as the outcomes of kidney failure requiring KRT, hospitalization, and pre-kidney failure death.

ANALYTICAL APPROACH

Marginal structural models with time-updated exposures.

RESULTS

Participants were followed up for a median of 6.84 years, with 391 (9.9%) and 612 (15.5%) reporting baseline opioid and NSAID use, respectively. Time-updated opioid use was associated with the kidney disease composite outcome, kidney failure with KRT, death (HRs of 1.4 [95% CI, 1.2-1.7], 1.4 [95% CI, 1.1-1.7], and 1.5 [95% CI, 1.2-2.0], respectively), and hospitalization (rate ratio [RR], 1.7; 95% CI, 1.6-1.9) versus opioid nonusers. Similar results were found in an analysis restricted to a subcohort of participants reporting ever using other (nonopioid and non-NSAID) analgesics or tramadol. Time-updated NSAID use was associated with increased risk for the kidney disease composite (HR, 1.2; 95% CI, 1.0-1.5) and hospitalization (RR, 1.1; 95% CI, 1.0-1.3); however, these associations were not significant in the subcohort. The association of NSAID use with the kidney disease composite outcome varied by race, with a significant risk in blacks (HR, 1.3; 95% CI, 1.0-1.7). NSAID use was associated with lower risk for kidney failure with KRT in women and individuals with glomerular filtration rate<45mL/min/1.73m² (HRs of 0.63 [95% CI, 0.45-0.88] and 0.77 [95% CI, 0.59-0.99], respectively).

LIMITATIONS

Limited periods of recall of analgesic use and potential confounding by indication.

CONCLUSIONS

Opioid use had a stronger association with adverse events than NSAIDs, with the latter's association with kidney disease outcomes limited to specific subgroups, notably those of black race.

The Evolving Landscape of Acute Pain Management in the Era of the Opioid Crisis

PURPOSE OF REVIEW

The purpose of the study is to evaluate and analyze the role of both opioid and non-opioid analgesics in the emergency department (ED).

RECENT FINDINGS

Studies have shown that the implementation of opioid-prescribing policies in the ED has the potential to reduce the opioid addiction burden. Clinical studies point to inconsistencies in providers' approach to pain treatment. In this review, we discuss specific aspects of opioid utilization and explore alternative non-opioid approaches to pain management. Pain is the most common reason patients present to the ED. As such, emergency medicine (EM) providers must be well versed in treating pain. EM providers must be comfortable using a wide variety of analgesic medications. Opioid analgesics, while effective for some indications, are associated with significant adverse effects and abuse potential. EM providers should utilize opioid analgesics in a safe and rational manner in an effort to combat the opioid epidemic and to avoid therapeutic misadventures. EM providers should be aware of all of their therapeutic options, e.g., opioid and non-opioid, in order to provide effective analgesia for their patients, while avoiding adverse effects and minimizing the potential for misuse.

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients

BACKGROUND AND OBJECTIVES

Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment).

RESULTS

The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture.

CONCLUSIONS

Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.

Regular use of pain medication due to musculoskeletal disorders in the general working population: Cross-sectional study among 10,000 workers

BACKGROUND

We aimed to determine the association between work, health, and lifestyle with regular use of pain medication due to musculoskeletal disorders in the general working population.

METHODS

Currently employed wage earners (N = 10,024) replied to questions about health, work, and lifestyle. The odds for regularly using medication for musculoskeletal disorders were modeled using logistic regression controlled for various confounders.

RESULTS

Pain intensity increased the odds for using pain medication in a dose-response fashion. With seated work as reference, the odds for using pain medication were 1.26 (95%CI: 1.09-1.47) for workers engaged in standing or walking work that is not strenuous and 1.59 (95%CI: 1.39-1.82) for workers engaged in standing or walking work with lifting tasks or heavy and fast strenuous work.

CONCLUSIONS

Workers with higher levels of physical activity at work are more likely to use pain medication on a regular basis for musculoskeletal disorders, even when adjusting for pain intensity, lifestyle, and influence at work. Am. J. Ind. Med. 59:934-941, 2016. © 2016 Wiley Periodicals, Inc.

Opioid-induced respiratory depression in the acute care setting: a compendium of case reports

SUMMARY 

Opioid-induced respiratory depression (OIRD) is a potentially fatal complication of treatment with opioids. Little is known about patient- and case-related factors associated with OIRD. One-hundred-and-five available case reports on OIRD in 134 patients (12 years and older) in the perioperative, obstetric or emergency care setting, published since 1980, were retrieved from the literature. The most frequently reported case-related factors were: morphine use, perioperative setting and obstetrics, neuraxial or intravenous administration. The most frequently reported patient-related factors involved were: female gender, sleep-disordered breathing, obesity, renal impairment, pulmonary disease and CYP450 enzyme polymorphisms. While the analysis has limitations, it confirms that OIRD in the acute setting involves complex and interrelated factors and is a significant cause of preventable morbidity and mortality.

Management of acute and post-operative pain in chronic kidney disease

Chronic kidney disease is common and patients with many co-morbid conditions frequently have to undergo surgical procedures and, therefore, require effective pain management. The pharmacokinetics of various analgesic agents are not well studied in patients with chronic kidney disease and the risk of accumulation of the main drug or their metabolites, resulting in serious adverse events, is a common scenario on medical and surgical wards. It is common for these patients to be cared for by 'non-nephrologists' who often prescribe the standard dose of the commonly used analgesics, without taking into consideration the patient's kidney function. It is important to recognize the problems and complications associated with the use of standard doses of analgesics, and highlight the importance of adjusting analgesic dosage based on kidney function to avoid complications while still providing adequate pain relief.

Management of acute and post-operative pain in chronic kidney disease

Chronic kidney disease is common and patients with many co-morbid conditions frequently have to undergo surgical procedures and, therefore, require effective pain management. The pharmacokinetics of various analgesic agents are not well studied in patients with chronic kidney disease and the risk of accumulation of the main drug or their metabolites, resulting in serious adverse events, is a common scenario on medical and surgical wards. It is common for these patients to be cared for by 'non-nephrologists' who often prescribe the standard dose of the commonly used analgesics, without taking into consideration the patient's kidney function. It is important to recognize the problems and complications associated with the use of standard doses of analgesics, and highlight the importance of adjusting analgesic dosage based on kidney function to avoid complications while still providing adequate pain relief.

Chronic kidney disease: pharmacological considerations for the dentist

BACKGROUND

Patients with chronic kidney disease (CKD) represent a challenge for the dentist seeking to prescribe medications. Understanding the medical management of renal insufficiency and the pharmacokinetics of common dental drugs will aid clinicians in safely treating these patients.

TYPES OF STUDIES REVIEWED

The authors reviewed the literature concerning the medical and pharmacological management of CKD. They reviewed the pharmacokinetic effects of drugs described in case reports and research articles and obtained from them recommendations regarding the use of drugs and adjustment of dosages.

CLINICAL IMPLICATIONS

Because CKD is progressive, patients have varying levels of renal function but do not yet have end-stage renal disease. Some drugs that dentists prescribe commonly may worsen a patient's renal function, lead to drug toxicity or both. Managing the care of patients and prescribing medications tailored to their needs begin with a recognition of the patient with renal disease at risk of developing adverse effects. Clinicians can identify these patients from information obtained in their medical histories and from the drugs they may be taking.

CONCLUSIONS

To treat patients with kidney disease, clinicians must recognize those at risk, have knowledge of the pharmacokinetic changes that occur and recognize that adjustment of drug dosages often is needed.

Lethal morphine intoxication in a patient with a sickle cell crisis and renal impairment: case report and a review of the literature

Morphine-6-glucuronide, the active metabolite of morphine, and to a lesser extent morphine itself are known to accumulate in patients with renal failure. A number of cases on non-lethal morphine toxicity in patients with renal impairment report high plasma concentrations of morphine-6-glucuronide, suggesting that this metabolite achieves sufficiently high brain concentrations to cause long-lasting respiratory depression, despite its poor central nervous system penetration. We report a lethal morphine intoxication in a 61-year-old man with sickle cell disease and renal impairment, and we measured concentrations of morphine and morphine-6-glucuronide in blood, brain and cerebrospinal fluid. There were no measurable concentrations of morphine-6-glucuronide in cerebrospinal fluid or brain tissue, despite high blood concentrations. In contrast, the relatively high morphine concentration in the brain suggests that morphine itself was responsible for the cardiorespiratory arrest in this patient. Given the fatal outcome, we recommend to avoid repeated or continuous morphine administration in renal failure.

An analysis of renal dysfunction in 1511 patients with fractured neck of femur: the implications for peri-operative analgesia

SUMMARY

Following two deaths from respiratory failure secondary to opioid toxicity in patients admitted for surgical repair of fractured neck of femur, we retrospectively studied the serum urea and electrolyte concentrations of 1511 consecutive patients requiring surgery for proximal femoral fracture, and calculated their glomerular filtration rate. Five hundred and forty-five (36.1%) patients had renal dysfunction on admission (glomerular filtration rate < 60 ml x min(-1).1.73 m(-2)); 435 (28.8%) had grade 3 chronic kidney disease (moderate; glomerular filtration rate 30-59 ml x min(-1).1.73 m(-2)), 82 (5.4%) had grade 4 disease (severe; glomerular filtration rate 15-29 ml x min(-1).1.73 m(-2)) and 28 (1.9%) had grade 5 (renal failure; glomerular filtration rate < 15 ml min(-1).1.73 m(-2)). The 30-day mortality for patients with renal dysfunction (62/536; 11.6%) was significantly greater (p = 0.004) than for patients with normal renal function (68/958; 7.1%), although median (IQR [range]) postoperative lengths of stay were similar 15 (10-22 [1-125]) vs 14 (9-22 [1-120]) days respectively; p = 0.06). Renal impairment is common in patients admitted for fixation of fractured neck of femur, who are consequently at risk of opioid toxicity.

Symptom management for the adult patient dying with advanced chronic kidney disease: a review of the literature and development of evidence-based guidelines by a United Kingdom Expert Consensus Group

Improvement in end-of-life-care is required for patients dying with chronic kidney disease (CKD). The UK government now recommends that tools such as the Liverpool Care Pathway for the Dying Patient (LCP) be used to enhance the care of those patients dying with CKD. The LCP was originally developed for patients dying with terminal cancer, however has been shown to be transferable to patients dying with heart failure or stroke. On this background, in 2005 a UK National Renal LCP Steering Group was formed. The aim was to determine whether or not the generic LCP was transferable to patients dying with CKD. An Expert Consensus sub-group was established to produce evidence-based prescribing guidelines to allow safe and effective symptom control for patients dying with renal failure. These guidelines were finalised by the Expert Consensus group in August 2007 and endorsed by the Department of Health in March 2008. A literature search on symptom control and end-of-life care in renal failure was performed. A summary of the evidence was presented at a National Steering Group meeting. Opinions were given and provisional guidelines discussed. A first draft was produced and individually reviewed by all members of the Expert Group. Following review, amendments were made and a second draft written. This was presented to the entire National Steering Group and again individual comments were taken into consideration. A third and fourth draft were written and individually reviewed, before the guidelines were finalised by the Expert Consensus group. Patients dying with advanced CKD suffer symptoms similar to patients dying of cancer. The Renal LCP prescribing guidelines aim to control the same symptoms as the generic LCP: pain, dyspnoea, terminal restlessness and agitation, nausea and respiratory tract secretions. The evidence for the production of the guidelines is discussed and how a consensus was reached. A summary of the guidelines is given and the complete guidelines document is available via the Marie Curie Palliative Care Institute, Liverpool website.

Opioid-related narcosis in a woman with myopathy receiving magnesium

An Asian multiparous woman weighing 47 kg, who suffered from a rare myopathy, congenital fibre type disproportion, was given morphine 10 mg intramuscularly for labour analgesia. After delivery, she had diastolic hypertension and proteinuria and was prescribed magnesium sulphate. Some hours later she became unresponsive with little respiratory effort. Blood gas analysis revealed a respiratory acidosis. Naloxone administration reversed the symptoms. Further doses were required as the respiratory depression recurred. Opioid-related narcosis is the most likely diagnosis in this case. Other possible differential diagnoses were magnesium overdose or a post-ictal state. The presence of a myopathy could render this patient susceptible to the respiratory effects of opioids. Other explanations for an exaggerated and delayed response to opioids include co-administration of other respiratory depressant drugs such as magnesium sulphate, co-morbidity such as renal impairment and genetic variability in the metabolism of morphine. Robust guidelines and highlighting patients with risk factors are required to prevent this complication from recurring.