Opioid Interruptions, Pain, and Withdrawal Symptoms in Nursing Home Residents

• Published in: Clinical therapeutics Vol. 36; no. 11; pp. 1555 - 1563
• Main Authors: Redding, Sarah E., MD, Liu, Sophia, MD, Hung, William W., MD, MPH, Boockvar, Kenneth S., MD, MS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2014; Elsevier Limited
• Subjects: Aged; Aged, 80 and over; Analgesics, Opioid - therapeutic use; Chronic illnesses; Cognitive ability; Drug dosages; Female; Hispanic Americans; Hospitalization; Hospitals; Humans; Hypertension; Internal Medicine; Laboratories; Male; Medical Education; Medical records; Middle Aged; Narcotics; Nursing homes; Nursing Homes - statistics & numerical data; Older people; opioid; Pain; Pain - drug therapy; pain management; Pain Measurement; Substance Withdrawal Syndrome - etiology; Surveillance; withdrawal; pain management; withdrawal; nursing homes; opioid
• ISSN: 0149-2918; 1879-114X
• DOI: 10.1016/j.clinthera.2014.10.013

Abstract Purpose Interruptions in opioid use have the potential to cause pain relapse and withdrawal symptoms. The objectives of this study were to observe patterns of opioid interruption during acute illness in nursing home residents and examine associations between interruptions and pain and withdrawal symptoms. Methods Patients from 3 nursing homes in a metropolitan area who were prescribed opioids were assessed for symptoms of pain and withdrawal by researchers blinded to opioid dosage received, using the Brief Pain Inventory Scale and the Clinical Opioid Withdrawal Scale, respectively, during prespecified time periods. The prespecified time periods were 2 weeks after onset of acute illness (eg, urinary tract infection), and 2 weeks after hospital admission and nursing home readmission, if they occurred. Opioid dosing was recorded and a significant interruption was defined as a complete discontinuation or a reduction in dose of >50% for ≥1 day. The covariates age, sex, race, comorbid conditions, initial opioid dose, and initial pain level were recorded. Symptoms pre- and post-opioid interruptions were compared and contrasted with those in a group without opioid interruptions. Findings Sixty-six patients receiving opioids were followed for a mean of 10.9 months and experienced a total of 104 acute illnesses. During 64 (62%) illnesses, patients experienced any reduction in opioid dosing, with a mean (SD) dose reduction of 63.9% (29.9%). During 39 (38%) illnesses, patients experienced a significant opioid interruption. In a multivariable model, residence at 1 of the 3 nursing homes was associated with a lower risk of interruption (odds ratio = 0.073; 95% CI, 0.009 to 0.597; P < 0.015). In patients with interruptions, there were statistically insignificant changes in mean (SD) pain score (difference −0.50 [2.66]; 95% CI, −3.16 to 2.16) and withdrawal score (difference −0.91 [3.12]; 95% CI, −4.03 to 2.21) after the interruption as compared with before interruption. However, when compared with patients without interruptions, patients with interruptions experienced larger increases in pain scores during the follow-up periods (difference 0.09 points per day; 95% CI, −0.01 to 0.019; P = 0.08). In particular, patients who received the highest quartile of opioid dose before interruption experienced increases in pain scores over time that were 0.22 points per day larger (95% CI, 0.02 to 0.41; P = 0.03) than those without interruption. Withdrawal scores were not associated with opioid interruption regardless of dose before interruption. Implications Nursing home patients often experience interruptions in opioid dosing, which can be associated with worse pain, but not withdrawal symptoms, during acute illnesses. Clinicians should be aware of the potential risks and effects of opioid interruptions during acute illnesses in this patient group.