Opioids linked to mortality in inflammatory bowel disease

Among patients with inflammatory bowel disease, opioid prescriptions tripled during a recent 20-year period, and heavy use of strong opioids was significant predictor of all cause mortality, according to large cohort study reported.

Because this study was retrospective, it could not establish causality. But “[de]signing and conducting a large-scale randomized control trial  may not be feasible.”

The gastrointestinal side effect of many analgesics complicate pain management for patients with IBD, who not only live with chronic abdominal pain, but also can develop arthropathy-related musculoskeletal pain,  and fibromyalgia. In addition to the risk of narcotic vowel associated with opioid use in IBD, opioids can mask flares in IBD or can cause toxic dilatation if administered during acute flares.

The investigators retrospectively studied 3,517 individuals with Crohn’s disease and 5,349 patients with ulcerative colitis from ResearchOne, a primary care electronic health records database that covers about 10% of patients in England. The data set excluded patients with indeterminate colitis or who underwent colectomy for ulcerative colitis.

From 1990 through 1993, only 10% of patients with IBD were prescribed opioids, vs. 30% from 2010 through 2013 (P less than .005).  After the investigators controlled for numerous demographic and clinical variables, being prescribed a strong opioid (morphine, oxycodone, fentanyl, buprenorphine, methadone, hydromorphone, or pethidine) more than three times per year significantly correlated with all-cause mortality in both Crohn’s disease (hazard ratio, 2.2) and ulcerative colitis (HR, 3.3) the researchers reported.

Among patients with ulcerative colitis, more moderate use of strong opioids (one to three prescriptions annually) also significantly correlated with all-cause mortality (HR, 2.4), as did heavy use of codeine (HR, 1.8) but these associations did not reach statistical significance among patients with Crohn’s disease. Tramadol was not linked to mortality in either IBD subtype when used alone or in combination with codeine.

Researchers said they could not control for several important potential confounders, including fistulating disease, quality of life, mental illness, substance abuse, and history of abuse.