A recent study was performed in Tennessee (see references) to compare all-cause mortality for patients with chronic non-cancer pain and no evidence of palliative or end-of-life care who were prescribed either long-acting opioids or alternative medications for moderate to severe chronic pain.

Propensity score-matching was used to compare new episodes of prescriptions for long-acting opioids versus either analgesic anticonvulsants (e.g. gabapentinoids) or low-dose cyclic antidepressants (control medications). Total and cause-specific mortality were determined from death certificates.

Of 22,912 new episodes of prescribed therapy for both long-acting opioids and control medications, the hazard ratios (HR) for total mortality was 1.64 (95% CI, 1.26-2.12) for those prescribed long-acting opioids.

Increased risk was due to out-of-hospital deaths (HR, 1.90; 95% CI, 1.40-2.58). For out-of-hospital deaths other than unintentional overdose, the HR was 1.72 (95% CI, 1.24-2.39). The HR for cardiovascular deaths was 1.65 (95% CI, 1.10-2.46). The HR during the first 30 days of therapy was 4.16 (95% CI, 2.27-7.63).

This recent data, taken in context of all that is known about chronic opioid use, would suggest that maximizing non-opioid analgesics (e.g. acetaminophen, NSAIDs, gabapentinoids, and antidepressants), is preferable to starting long-acting opioids for non-cancer, non-palliative pain management.

As this form of pain management can be complex and nuanced, it is appropriate to seek a consult from a pain management expert prior to initiating long-acting opioids. In summary, prescription of long-acting opioids for chronic non-cancer pain compared to anticonvulsants or cyclic antidepressants was associated with a significantly increased risk of all-cause mortality, including deaths from causes other than overdose.

References:

• Ray WA, Chung CP, Murray KT, et al. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016; 315(22):2415-2419.