Post on 18-Jul-2020
Narcotic use and misuse in Crohn’s disease
Crocker et alInflammatory Bowel Diseases 2014; 20:2234
Charles Bernstein, MD, Associate Editor IBDUniversity of Manitoba, Winnipeg, MB
Financial Interest Disclosure(over the past 24 months)
Commercial Interest Relationship
Abbvie Canada advisory board, investigator, speaker support, education support
Shire Canada advisory board, education support
Takeda Canada advisory board, education support
Pfizer advisory board
Cubist advisory board
Forrest Canada advisory board
Name: Dr. Charles Bernstein
2015 CDDW/CASL Winter Meeting
X Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician Role in the CanMEDS framework.)
Communicator (as Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.)
Collaborator (as Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.)
Manager (as Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system.)
Health Advocate (as Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.)
X Scholar (as Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.)
Professional (as Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.)
CanMEDS Roles Covered:
• Retrospective review of 914 CD patients attending the U Virginia GI clinic 2006‐2011
• Assessed narcotic use including by concurrent dx of FGID
• Narcotic misuse defined as narcotic Rx filled from ≥4 prescribers and from ≥4 pharmacies
Crocker IBD 2014
• Didn’t describe how FGID was diagnosed
• Excluded codeine in evaluation
Crocker IBD 2014
RESULTS
• 20% using chronic narcotics• 9.3% with FGID• FGID + narcotics=44%• noFGID + narcotics=18%• Narcotic misuse=59% of users, 12%
overall• Misuse; FGID=37%, no FGID=10%
Crocker IBD 2014
Chronic narcotic use in CDNarcotic users(N=192)
Nonusers(n=739)
P value Odds ratio(multivariate)
Female 66% 53% 0.001
Disability 16% 5% <0.0001 2.37 (1.12‐5.0)
Tobacco use 37% 22% <0.0001 1.53 (0.95‐2.45)
Anxiety 20% 7% <0.0001 2.16 (1.19‐3.94)
Depression 33% 15% <0.0001 1.69 (1.03‐2.77)
Substance abuse
6% 2% 0.01 3.02 (1.17‐7.77)
Migraines 15% 5% <0.0001 1.01 (0.48‐2.15)
Fibromyalgia 5% 1% 0.003
FGID 20% 6% <0.0001 3.33 (1.87‐5.93)
Crocker IBD 2014
Retrospective chart review‐Medical College of Wisconsin
• CD (n=291) ‘98‐’03• Narcotic use 13.1%. • Female, 72% vs 49% (p= 0.01), • Disability, 15.4% vs 3.6% (p= 0.001), • Longer duration of disease, 17.0 vs 12.9 yr (p= 0.03). • Neuropsych drug use, 37% vs 19% (p= 0.01).
Multivariate analysis: • Polypharmacy‐use of 5 drugs (OR 5.5)• smoking (OR 2.8)
Cross Am J Gastroenterol 2005
Case control study of narcotic users at Mayo Clinic
• 100 cases and 100 matched controls ’99‐’02.• Female 64% vs 45% P = 0.01• ≥2 IBD‐related surgeries 42% vs 17%, P < 0.001• Moderate‐to‐severe pain 93% vs 20%, P < 0.001, • Depression 42% vs 19%, P < 0.001, • Anxiety 19% vs 7%, P = 0.02, • Abuse hx (sexual, emotional, or physical, 17% vs 3%, P = 0.006,
• Substance abuse (excluding alcohol) 14% vs 1%, P = 0.01
Hanson IBD 2009
TREAT RegistryPredictors of Mortality
Variable Hazard ratio (95% CI)
Infliximab 0.83 (0.6, 1.15)
Prednisone 2.14 (1.6, 2.95)
Immunomodulator 0.86 (0.62, 1.18)
Narcotics 1.79 (1.29, 2.48)
Lichtenstein Am J Gastroenterol 2012
Retrospective cohort study of adult IBD patients admitted at UNC
• 117 patients ‘08‐’09; Narcotics were given to 70.1%.• Crohn's disease; P ≤0.01, • Duration of IBD, P = 0.02, • Prior psychiatric diagnosis, P = 0.02• Outpatient narcotic use, P ≤ 0.01, • Current smoking, P ≤ 0.01, • Prior IBD‐specific surgery, P < 0.02, • prior IBS diagnosis, P = 0.02. Multivariate analysis:smoking (OR= 4.34, 1.21–15.6) prior outpatient narcotic use (OR 5.41, 1.54–19.0)
Long IBD 2012
The prevalence and predictors of opioid use in inflammatory bowel disease: a
population based analysis
Targownik et alAm J Gastroenterol 2014; 109:1613
Study Design
• Patient population– UMIBDED since 1996 – Subjects followed from time of IBD dx until
• Death• Colectomy (subjects with UC)• Outmigration• Diagnosis of non-melanoma skin cancer
Targownik Am J Gastroenterol 2014
Study Design
• Main outcomes– Prevalence of active opioid use
• Defined as dispensation of opioid medications within 60d
– Time to heavy opioid use• Defined as >50mg of morphine equivalents/day used for ≥30 d
consecutively• All subjects who were heavy users prior to 90d before diagnosis
date excluded• First 90 days after diagnosis were censored
– Predictors of Heavy Use• Cox proportional hazards model of time to heavy use
Targownik Am J Gastroenterol 2014
11.7%
7.3%
5.9%
4.3%
Heavy opioid use
Subjects with IBD vs controlsHR 2.91, 95% CI 2.19–3.85
Targownik Am J Gastroenterol 2014
By Sex
Targownik Am J Gastroenterol 2014
By sex; prior to IBD Dx
Targownik Am J Gastroenterol 2014
0%
2%
4%
6%
8%
10%
0 2 4 6 8 10 12 14 16
% H
eavy
Use
rs
Years from Diagnosis of IBD
Time to Becoming a Heavy Opioid User: Stratified by Disease Subtype
CD Case CD Control
UC Case UC Control
5.4%CD
3.5%UC
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
0 2 4 6 8 10
% H
eavy
Use
rs
Years from IBD Diagnosis
Time to Becoming a Heavy Opioid User: Stratified by Prior Narcotic Use
Any Opioid Use, 365-91d pre Dx
No Opioid Use Prior to Dx
9.1% @ 5 years
1.0% @ 5 years
Adjusted HR 95% CI
Non‐Heavy Use of Opioids Prior to IBD Diagnosis
6.43 4.28 ‐ 9.66
Osteoarthritis 2.22 1.45 ‐ 3.40Back Pain 2.53 1.72 ‐ 3.81Depression 2.07 1.25 ‐ 3.36
Risk Factors for Heavy Opioid Use in IBD
Targownik Am J Gastroenterol 2014
Adjusted OR 95% CI
Heavy Opioid Use 2.84 1.58 - 5.12
Substance Abuse 11.7 2.41 - 56.9Any Use of Psycho-active Drugs 1.64 1.28 - 2.11
Hospital Visits3+ visits 8.58 5.74 - 12.82 visits 6.50 4.30 - 9.811 visit 2.73 2.02 - 3.69None Ref Ref
Association between Heavy Opioid Use and Mortality in IBD using Cox Proportional Hazard Modeling
Targownik Am J Gastroenterol 2014
Opioid use in IBD‐summary
• Beware of opioid use prior to Dx• Females, Psych History, Substance
abuse, Disability, Smoking• Association with death
• LIMIT THE USE OF OPIOIDS IN IBD