Increased Risk of Falls, Fractures and Narcotics

Chicago—Current guidelines that recommend short-term narcotic analgesics (NAs) as first-line treatment for managing chronic pain may need to be reevaluated based on new data that show an increased risk of falls and fractures in elderly patients with osteoarthritis treated with NAs. Results were presented at the ACR meeting in a poster titled Unintended Consequences, Increased Prescription of Narcotic Analgesics for OA in the Elderly Is Associated with Increased Falls and Fractures in the Post-Vioxx Era. Investigators retrospectively examined whether changes in the types of drugs prescribed for pain were associated with changes in the rate of falls and fractures among elderly patients with osteoarthritis. With the removal from the market of the selective cyclooxygenase (COX)-2 inhibitor, rofecoxib, in 2004 because of cardiovascular safety issues, NAs have emerged as first-line treatment for chronic pain as recommended by the American Heart Association and American Geriatrics Society. The current study was done to assess whether this change in chronic pain management in the elderly was associated with changes in falls and fractures, since NAs contribute to falls in the elderly. The importance of preventing or reducing falls in the elderly is highlighted by statistics that show that falls in the elderly result in severe injury in 32% of patients ≥65 years of age and incur a high cost burden on the healthcare system. Medical costs for falls in 2000 were $19 billion. Using electronic medical records for care from the Geisinger electronic medical record data warehouse, an integrated health system in rural Pennsylvania, investigators identified 13,354 patients between 65 and 89 years of age who were diagnosed with osteoarthritis and received care between 2001 and 2009. This time span represents the midpoint when rofecoxib was taken off the market. Patients diagnosed with falls and fractures were identified through International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were grouped by type of treatment: those treated with NAs with or without other pain medication, those treated with COX-2 alone or with other pain medication, and those treated with nonsteroidal anti-inflammatory drugs (NSAIDs) with or without other pain medications excluding narcotics and COX-2 selective agents. The study found that NA prescriptions increased steadily over the study period from 8% in 2001 to 20% in 2004 and doubled to 40% by 2009, whereas the prescription of COX-2 agents peaked at 10% in 2004 followed by a rapid decline to 4% thereafter. During this time, the fall rates for the entire group increased 3-fold, with the incidence of falls or fractures increasing from <1% of all patients in 2001 to 4% in 2009. The study found that patients treated with narcotics had significantly more falls or fractures compared with those treated with COX-2 agents or NSAIDs, with an odds ratio (OR) of 3.3 (95% confidence interval [CI], 2.5-4.3) and 4.1 (95% CI, 3.7-4.5), respectively (P<.001 for both comparisons). The rate of falls or fractures was similar in patients treated with COX-2 agents and NSAIDs. The risk of falls or fractures also increased in patients treated with NAs in both study periods. NA use was associated with a 3.7 OR (95% CI, 2.6-5.4; P<.001) compared with COX-2 agents and a 4.4 OR (95% CI, 3.9-4.9; P<.001) compared with NSAIDs between 2005 and 2009, and a 2.5 OR (95% CI, 1.7-3.6; P<.001) compared with COX-2 agents and a 3.0 OR (95% CI, 2.4-3.7; P<.001) compared with NSAIDs between 2001 and 2004. The investigators also looked at the influence of age and comorbidities on falls or fractures during this time period. Overall, the study found that patients with falls were older than those without falls (a median of 78.1 years of age vs 73.8 years of age) regardless of treatment type. Only the patients with falls treated by NAs, however, also had higher comorbidities. According to Lydia Rolita, MD, the study’s lead author from the Montefiore Medical Center at Albert Einstein College of Medicine, Bronx, New York, these findings indicate the need to reevaluate current recommendations for the treatment of chronic pain. However, she emphasized more research is needed before new guidelines are developed.