The Association Between Prescribed Opioid Receipt and Community-Acquired Pneumonia in Adults: a Systematic Review and Meta-analysis

Safe Management of Adverse Effects Associated with Prescription Opioids in the Palliative Care Population: A Narrative Review

In the palliative care population, prescription opioids are often considered viable pain relief options. However, in this complex patient population, the adverse effects of opioid medications should be identified and managed without delay. Common adverse effects can include constipation, nausea, somnolence, dizziness, vomiting, and pruritus. Less common adverse effects can include potentially lethal respiratory depression and cardiovascular effects. Critical aspects of safe opioid prescribing are recognition of side effects and knowledge of effective management strategies; prompt management is necessary for uninterrupted pain relief. Most complications are managed with general approaches such as dose reduction, opioid rotation, alternate routes of administration, and symptomatic management. The only opioid-induced complication for which US Food and Drug Administration-approved treatments currently exist is constipation. Treating laxative-refractory opioid-induced constipation (OIC) with peripherally acting mu-opioid receptor antagonists (PAMORAs), which block gastrointestinal opioid receptors, can restore gastrointestinal motility and fluid secretion. This narrative review discusses key complications of prescription opioid treatment and their management in the palliative care setting.

The Association of Prescribed Opioids and Incident Cardiovascular Disease

Opioid prescribing remains common despite known overdose-related harms. Less is known about links to nonoverdose morbidity. We determined the association between prescribed opioid receipt with incident cardiovascular disease (CVD) using data from the Veterans Aging Cohort Study, a national prospective cohort of Veterans with/without Human Immunodeficiency Virus (HIV) receiving Veterans Health Administration care. Selected participants had no/minimal prior exposure to prescription opioids, no opioid use disorder, and no severe illness 1 year after the study start date (baseline period). We ascertained prescription opioid exposure over 3 years after the baseline period using outpatient pharmacy fill/refill data. Incident CVD ascertainment began at the end of the prescribed opioid exposure ascertainment period until the first incident CVD event, death, or September 30, 2015. We used adjusted Cox proportional hazards regression models with matching weights using propensity scores for opioid receipt to estimate CVD risk. Among 49,077 patients, 30% received opioids; the median age was 49 years, 97% were male, 49% were Black, and 47% were currently smoking. Prevalence of hypertension, diabetes, current smoking, alcohol and cocaine use disorder, and depression was higher in patients receiving opioids versus those not but were well-balanced by matching weights. Unadjusted CVD incidence rates per 1,000-person-years were higher among those receiving opioids versus those not: 17.4 (95% confidence interval [CI], 16.5-18.3) versus 14.7 (95% CI, 14.2-15.3). In adjusted analyses, those receiving opioids versus those not had an increased hazard of incident CVD (adjusted hazard ratio 1.16 [95% CI, 1.08-1.24]). Prescribed opioids were associated with increased CVD incidence, making opioids a potential modifiable CVD risk factor. PERSPECTIVE: In a propensity score weighted analysis of Veterans Administration data, prescribed opioids compared to no opioids were associated with an increased hazard of incident CVD. Higher opioid doses compared with lower doses were associated with increased hazard of incident CVD. Opioids are a potentially modifiable CVD risk factor.

Dysphagia as a Missing Link Between Post-surgical- and Opioid-Related Pneumonia

PURPOSE

Postoperative pneumonia remains a common complication of surgery, despite increased attention. The purpose of our study was to determine the effects of routine surgery and post-surgical opioid administration on airway protection risk.

METHODS

Eight healthy adult cats were evaluated to determine changes in airway protection status and for evidence of dysphagia in two experiments. (1) In four female cats, airway protection status was tracked following routine abdominal surgery (spay surgery) plus low-dose opioid administration (buprenorphine 0.015 mg/kg, IM, q8-12 h; n = 5). (2) Using a cross-over design, four naive cats (2 male, 2 female) were treated with moderate-dose (0.02 mg/kg) or high-dose (0.04 mg/kg) buprenorphine (IM, q8-12 h; n = 5).

RESULTS

Airway protection was significantly affected in both experiments, but the most severe deficits occurred post-surgically as 75% of the animals exhibited silent aspiration.

CONCLUSION

Oropharyngeal swallow is impaired by the partial mu-opioid receptor agonist buprenorphine, most remarkably in the postoperative setting. These findings have implications for the prevention and management of aspiration pneumonia in vulnerable populations.

Serotonin therapies for opioid-induced disordered swallow and respiratory depression

Opioids are well-known to cause respiratory depression, but despite clinical evidence of dysphagia, the effects of opioids on swallow excitability and motor pattern are unknown. We tested the effects of the clinically relevant opioid buprenorphine on pharyngeal swallow and respiratory drive in male and female rats. We also evaluated the utility of 5-HT1A agonists (8-OH-DPAT and buspirone) to improve swallowing and breathing following buprenorphine administration. Experiments were performed on 44 freely breathing Sprague-Dawley rats anesthetized with sodium pentobarbital. Bipolar fine wire electrodes were inserted into the mylohyoid, thyroarytenoid, posterior cricoarytenoid, thyropharyngeus, and diaphragm muscles to measure electromyographic (EMG) activity of swallowing and breathing. We evaluated the hypotheses that swallowing varies by stimulus, opioids depress swallowing and breathing, and that 5-HT1A agonists improve these depressions. Our results largely confirmed the following hypotheses: 1) swallow-related EMG activity was larger during swallows elicited by esophageal distension plus oral water infusion than by either stimulus alone. 2) Buprenorphine depressed swallow in both sexes, but females were more susceptible to total swallow suppression. 3) Female animals were also more vulnerable to opioid-induced respiratory depression. 4) 8-OH-DPAT rescued breathing following buprenorphine-induced respiratory arrest, and pretreatment with the partial 5-HT1A agonist buspirone prevented buprenorphine-induced respiratory arrest in female animals. 5) 8-OH-DPAT enhanced mylohyoid and thyropharyngeus EMG amplitude during swallow but did not restore excitability of the swallow pattern generator following total suppression by buprenorphine. Our results highlight sex-specific and behavior-specific effects of buprenorphine and provide preclinical evidence of a 5HT1A agonist for the treatment of respiratory depression and dysphagia.NEW & NOTEWORTHY This is the first study, to our knowledge, to evaluate sex-specific effects of opioid administration on pharyngeal swallow. We expand on a small but growing number of studies that report a lower threshold for opioid-induced respiratory depression in females compared with males, and we are the first to produce this effect with the partial μ-opioid-receptor agonist buprenorphine. This is the first demonstration, to our knowledge, that activation of 5-HT1A receptors can improve swallow and breathing outcomes following systemic buprenorphine administration.

Problems with opioids - beyond misuse

The U.S. is grappling with an opioid epidemic, with millions of adults on long-term opioid therapy (LTOT). Although patients often report pain relief and improved daily function with opioids, research shows no significant differences in short-term outcomes between opioid and non-opioid users, as well as no long-term opioid benefits. This scoping review aims to identify lesser-known side effects of long-term opioid use and increase awareness of them, allowing healthcare providers and patients to better assess the risks and benefits of opioid use. Our data search from PubMed and Google Scholar used keywords related to opioids, chronic pain, hypogonadism, endocrinopathies, cancer progression, cardiovascular events, renovascular events, sleep disturbances, mood disorders and others, narrowing down to English-language full articles published from January 2018 to April 2023. This review emphasizes the probable serious adverse consequences of long-term opioid use on various body systems in patients with chronic pain. Given the lack of long-term benefits and significant adverse effects, our review underscores the critical need for healthcare providers to include these risks in discussions with patients when considering the long-term use of opioid therapy.

Opioids and Immunosuppression: Clinical Evidence, Mechanisms of Action, and Potential Therapies

Background

In addition to the more well-known adverse effects of opioids, such as constipation, mounting evidence supports underlying immunosuppressive effects as well.

Methods

In this study, we provide a narrative review of preclinical and clinical evidence of opioid suppression of the immune system as well as possible considerations for therapies.

Results

In vitro and animal studies have shown clear effects of opioids on inflammatory cytokine expression, immune cell activity, and pathogen susceptibility. Observational data in humans have so far supported preclinical findings, with multiple reports of increased rates of infections in various settings of opioid use. However, the extent to which this risk is due to the impact of opioids on the immune system compared with other risk factors associated with opioid use remains uncertain. Considering the data showing immunosuppression and increased risk of infection with opioid use, measures are needed to mitigate this risk in patients who require ongoing treatment with opioids. In preclinical studies, administration of opioid receptor antagonists blocked the immunomodulatory effects of opioids.

Conclusions

As selective antagonists of peripheral opioid receptors, peripherally acting mu-opioid receptor (MOR) antagonists may be able to protect against immune impairment while still allowing for opioid analgesia. Future research is warranted to further investigate the relationship between opioids and infection risk as well as the potential application of peripherally acting MOR antagonists to counteract these risks.

Opioid prescription and risk of atrial fibrillation in younger veterans

BACKGROUND

Opioids may play a part in the development of atrial fibrillation (AF). Understanding the relationship between opioid exposure and AF can help providers better assess the risk and benefits of prescribing opioids.

OBJECTIVE

To assess the incidence of AF as a function of prescribed opioids and opioid type.

DESIGN

We performed unadjusted and adjusted time-updated Cox regressions to assess the association between opioid exposure and incident AF.

PARTICIPANTS

The national study sample was comprised of Veterans enrolled in the Veterans Health Administration (VHA) who served in support of post-9/11 operations.

MAIN MEASURES

The main predictor of interest was prescription opioid exposure, which was treated as a time-dependent variable. The first was any opioid exposure (yes/no). Secondary was opioid type. The outcome, incident AF, was identified through ICD-9-CM diagnostic codes at any primary care visit after the baseline period.

KEY RESULTS

A total of 609,763 veterans (mean age: 34 years and 13.24% female) were included in our study. Median follow-up time was 4.8 years. Within this cohort, 124,395 veterans (20.40%) were prescribed an opioid. A total of 1,455 Veterans (0.24%) were diagnosed with AF. In adjusted time-updated Cox regressions, the risk of incident AF was higher in the veterans prescribed opioids (hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.38-1.57). In adjusted time-updated Cox regressions, both immunomodulating and nonimmunomodulating opioid type was associated with increased risk of incident AF (HR: 1.40; 95% CI: 1.25-1.57 and HR: 1.49; 95% CI: 1.39-1.60), compared to no opioid use, respectively.

CONCLUSIONS

Our findings suggest opioid prescription may be a modifiable risk factor for the development of AF.

Prenatal Opioid Exposure and Immune-Related Conditions in Children

Importance

Prenatal opioid exposure (POE) may alter with fetal development of the immune system, which may influence long-term health and susceptibility to immune-related conditions.

Objective

To compare the risk of hospitalization and emergency department presentation for immune-related conditions in children with and without POE.

Design, Setting, and Participants

This retrospective, population-based cohort study used linked administrative health records of all children born in Western Australia between January 1, 2003, and December 31, 2018 (N = 401 462).

Exposure

Prenatal exposure to prescription opioids (overall and by trimester), neonatal abstinence syndrome diagnosis, and opioid indication (pain or opioid use disorder [OUD]).

Main Outcomes and Measures

The main outcome was hospital admissions and emergency department presentations during which a child was diagnosed with an immune-related condition, including infections, conditions associated with an overactive immune system (eg, asthma, eczema, and allergy and anaphylaxis), and autoimmune diseases diagnosed before age 5 years or June 30, 2020. Data were analyzed between August 30, 2022, and February 27, 2023.

Results

Neonates with POE (1656 [0.4%]; mean [SD] gestational age, 37.7 [2.1] weeks; 836 females [50.5%]; 820 males [49.5%]) were more likely to be born preterm, have low birth weight for gestational age, and be coexposed to cigarette smoke compared with nonexposed neonates. Perinatal opioid exposure was associated with an increased risk of perinatal infection (adjusted odds ratio [AOR], 1.62; 95% CI, 1.38-1.90) and eczema and dermatitis (AOR, 11.91; 95% CI, 9.84-14.41) compared with nonexposure. Neonatal abstinence syndrome was also associated with both conditions (AOR, 2.91 [95% CI, 2.36-3.57] and 31.11 [95% CI, 24.64-39.28], respectively). Prenatal opioid exposure was also associated with an increased risk of childhood asthma (adjusted hazard ratio [AHR], 1.44; 95% CI, 1.16-1.79), but not allergies and anaphylaxis. It was also associated with an increased risk of childhood eczema and dermatitis, but only in children with POE from opioids used to treat OUD (AHR, 1.47; 95% CI, 1.08-1.99) rather than pain. In contrast, POE from opioids used for pain was associated with an increased risk of infection (AHR, 1.44; 95% CI, 1.32-1.58), but POE to opioids used to treat OUD was not. Autoimmune conditions were rare and were not observed to be associated with POE.

Conclusions and Relevance

In this cohort study, POE was associated with an increased risk of infection, eczema and dermatitis, and asthma, but not allergies and anaphylaxis or autoimmune conditions. These findings highlight the importance of further study of opioid-induced immune changes during pregnancy, the potential impact on long-term health in exposed children, and the mechanisms of opioid-induced immune dysregulation.

Risk factors of pneumonia in persons with and without Alzheimer's disease: a matched cohort study

BACKGROUND

Pneumonia is a very common infection in the cognitively impaired adult population, often leading to long-term deterioration, in physical and cognitive performance. Evidence is lacking on whether chronic comorbidities and drug use are risk factors for pneumonia in persons with Alzheimer's disease (AD). The objective of this study was to investigate the risk factors of pneumonia in community dwellers with and without AD.

METHODS

We performed a retrospective register-based study utilizing the Medication Use and Alzheimer's disease (MEDALZ) cohort, which is based on Finnish nationwide healthcare registers and includes all community dwellers who received a verified clinical diagnosis of AD between 2005 to 2011. This study comprised 69,350 persons with AD and 69,350 persons without AD matched by age, gender, and region of residence. Association between comorbidities, drug use, and hospitalization due to pneumonia were assessed using Cox Regression.

RESULTS

During the follow-up, 25.0% (n = 17,105) of the AD cohort and 15.8% (n = 10,966) of the non-AD cohort were hospitalized due to pneumonia. Persons with AD had a higher risk of pneumonia also after adjusting for comorbidities (HR 1.76, 95% CI 1.71-1.80). Previous pneumonia was the strongest risk factor for pneumonia in both cohorts. All comorbidities and drug use excluding biological product use were associated with a higher risk of pneumonia, but stronger associations were observed in the non-AD cohort. The risk of hospitalization following psychotropic drug use was proportional to the number of psychotropics utilized.

CONCLUSIONS

Pneumonia is a serious, potentially life-threatening illness, and risk factors for pneumonia include several potentially avoidable drugs. In addition, good care of existing comorbidities might prevent pneumonia and related hospitalization.

Association between Substance Misuse and Outcomes in Critically III Patients with Pneumonia

Rationale: In patients with pneumonia requiring intensive care unit (ICU) admission, alcohol misuse is associated with increased mortality, but the relationship between other commonly misused substances and mortality is unknown. Objectives: We sought to establish whether alcohol misuse, cannabis misuse, opioid misuse, stimulant misuse, or misuse of more than one of these substances was associated with differences in mortality among ICU patients with pneumonia. Methods: This was a retrospective cohort study of hospitals participating in the Premier Healthcare Database between 2010 and 2017. Patients were included if they had a primary or secondary diagnosis of pneumonia and received antibiotics or antivirals within 1 day of admission. Substance misuse related to alcohol, cannabis, stimulants, and opioids, or more than one substance, were identified from the International Classification of Diseases (Ninth and Tenth Editions). The associations between substance misuse and in-hospital mortality were the primary outcomes of interest. Secondary outcomes included the measured associations between substance misuse disorders and mechanical ventilation, as well as vasopressor and continuous paralytic administration. Analyses were conducted with multivariable mixed-effects logistic regression modeling adjusting for age, comorbidities, and hospital characteristics. Results: A total of 167,095 ICU patients met inclusion criteria for pneumonia. Misuse of alcohol was present in 5.0%, cannabis misuse in 0.6%, opioid misuse in 1.5%, stimulant misuse in 0.6%, and misuse of more than one substance in 1.2%. No evidence of substance misuse was found in 91.1% of patients. In unadjusted analyses, alcohol misuse was associated with increased in-hospital mortality (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.06-1.19), whereas opioid misuse was associated with decreased in-hospital mortality (OR, 0.46; 95% CI, 0.39-0.53) compared with no substance misuse. These findings persisted in adjusted analyses. Although cannabis, stimulant, and more than one substance misuse (a majority of which were alcohol in combination with another substance) were associated with lower odds for in-hospital mortality in unadjusted analyses, these relationships were not consistently present after adjustment. Conclusions: In this study of ICU patients hospitalized with severe pneumonia, substance misuse subtypes were associated with different effects on mortality. Although administrative data can provide epidemiologic insight regarding substance misuse and pneumonia outcomes, biases inherent to these data should be considered when interpreting results.

[The challenges of managing thoracic pain in cystic fibrosis (CF)]

BACKGROUND

Cystic fibrosis (CF) is a rare genetic multisystemic disorder with progressive abdominal and pulmonary involvement. Pain is still an underestimated symptom in CF patients.

METHODS

A comprehensive review of guidelines and scientific literature on the topic was performed and combined with findings from pain management in a young CF patient with progressive thoracic pain.

RESULTS

German CF guidelines do not cover diagnosis and management of pain in these patients. Studies from Europe and the United States report interactions between intensity of pain and mortality in CF, but do not include data on the efficacy of pain management. These data and clinical observations of a CF patient with episodes of intense thoracic pain are used to illustrate the specific challenges in pain relief.

CONCLUSION

Pain management in CF requires meticulous monitoring as well as an interdisciplinary approach and should be implemented in the German CF guidelines. The authors also want to suggest recommendations for the treatment of thoracic pain in CF. The range and severity of organ involvement complicates the use both of opioids and non-opioids. Especially opioid treatment carries the risk of hypoxia and opioid-induced constipation (OIC) and needs close medical supervision.

Effectiveness of online training of first and second year AEGD residents in identifying, referring, and managing patients at-risk for substance use and opioid disorders

BACKGROUND AND OBJECTIVES

Dentists have contributed greatly to the opioid epidemic, dispensing roughly 8.6% of opioids totaling over 18 million prescriptions in a 12-month period from July 2016 to June 2017 and report educational gaps regarding screening techniques for substance misuse and an unfamiliarity with available referral resources. The purpose of this study was to determine the knowledge and comfort level of residents in identifying, referring, and managing patients who are at risk for opioid use or substance use disorder in the dental setting before and after an online case-based training course.

METHODS

Thirty-five first year (PGY1) and 11 second year (PGY2) advanced education in general dentistry (AEGD) residents participated in an online training course that aimed to assess knowledge in the domains of identifying, referring, and managing patients at risk for substance abuse disorder and opioid use in an academic setting. There were nine subdomains within the three major domains that further assessed resident comfort and knowledge. Before and after training, data were collected and analyzed.

RESULTS

Analysis of the results indicated that (1) the training modules increased resident comfort in identifying (p = 0.011), referring (p = 0.032), and managing (p = 0.002) patients at risk for opioid substance use. (2) PGY1 residents benefited more than PGY2 residents in identifying (p = 0.034) and the manage domains (p < 0.001). (3) Residents viewed the module quality, usefulness, and applicability favorably. Further analysis of the nine subdomains is presented.

CONCLUSION

Our study suggests that dental curricula would benefit from incorporating training of residents in identifying, referring, and managing patients at risk for substance use disorder and opioid use.

The Reasons for Higher Mortality Rate in Opium Addicted Patients with COVID-19: A Narrative Review

The outbreak of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) caused COVID-19 has developed into an unexampled worldwide pandemic. The most important cause of death in patients with COVID-19 is Acute Respiratory Distress Syndrome (ARDS). Opium is widely used for its analgesic features in control of acute and chronic pain related to different diseases. Opium consumption is increased over the last three decades and leads to adverse effects on the respiratory system; opium also affects the lungs' functions and respiration. The contemplative issue is the higher mortality rate due to SARS-CoV-2 infection in opium addicts' patients. Studies have shown that despite the decrease in proinflammatory cytokines production in opium addicts, there are at least 4 reasons for this increase in mortality rate: downregulation of IFNs expression, development of pulmonary edema, increase thrombotic factors, increase the expression of Angiotensin-converting enzyme 2 (ACE2). Therefore, identifying the causes of mortality and approved therapies for the treatment of COVID-19 patients who use opium for any reason is an important unmet need to reduce SARS-CoV-2 infection-related mortality. This review study demonstrated the effects of opium on immune responses and the reasons for the higher mortality rate in opium addicts' patients with COVID-19.

Mantenimiento de tratamientos crónicos en pacientes afectados de COVID-19

•Los pacientes en tratamiento con IECA o ARAII no tienen mayor riesgo de infección por SARS-COVID, ni mayor riesgo de COVID-19 grave ni de mortalidad. Por ello, deben continuar con el tratamiento, y solo estaría justificada su retirada por motivos clínicos. •Los pacientes con COVID-19 en tratamiento con hipolipemiantes deben continuar con ellos, especialmente aquellos con alto riesgo de enfermedad cardiovascular. Se suspenderán si hay riesgo hepático o renal o si está impedida la vía oral. Se valorará el cambio de estatina si hay interacción con el tratamiento para la infección. •En pacientes diabéticos con COVID-19 se recomienda suspender los iSGLT-2 (gliflozinas o uricosúricos) en caso de fiebre o diarrea, y vigilar función renal y glucemia por si es necesario ajustar el resto de los antidiabéticos. La insulina es el tratamiento de elección en caso de retirada del resto de fármacos. •Los medicamentos psicotrópicos pueden interactuar con los fármacos utilizados para la COVID-19 y algunos de sus efectos adversos, especialmente los relacionados con la depresión respiratoria, pueden empeorar la evolución de la infección. •No se ha encontrado asociación entre el uso de inhibidores de la bomba de protones o anti-H2 y la aparición de COVID-19. La evidencia actual no indica la necesidad de retirar el omeprazol en los casos con clara indicación. •No hay evidencia científica que relacione el uso de antiinflamatorios no esteroideos (AINE) con el empeoramiento de la COVID-19, por lo que pueden usarse en el tratamiento sintomático de la infección y/u otras comorbilidades asociadas. •No se deben interrumpir los tratamientos crónicos con AINE u opiáceos que están bien indicados. Se recomienda elegir opioides con menos efecto inmunosupresor. •Durante la COVID-19 se recomienda suspender temporalmente los anticonceptivos y continuar con los anticoagulantes o antiagregantes que tomase previamente.

A double-edged sword of using opioids and COVID-19: a toxicological view

Today, COVID-19 is spreading around the world. Information about its mechanism, prognostic factors, and management is minimal. COVID-19, as a human disease, has several identifying phases. Physicians of patients with COVID-19 may be interested in knowing whether opioid use disorder may affect their patients' course or prognosis. This information may be crucial when considering the opioid epidemic in the US and other parts of the world. Opioid use at high doses and over several months duration can mitigate the immune system's function, which may complicate the course of COVID-19 disease. Potential suppression of parts of the immune response may be important in prevention, clinical support, and therapeutic use of medications in various phases of the COVID-19. Specifically, opioid use disorders via an inhalation route may enhance the "late hyper-inflammatory phase" or result in end-organ damage. It is well established that opioids decrease ventilation as their effect on the medullary respiratory centers increases the risk of pneumonia. This increased risk has been associated with immune-suppressive opioids. The ultimate role of opioids in COVID-19 is not clear. This paper endorses the need for clinical studies to decipher the role and impact of chronic opioid use on viral diseases such as COVID-19.