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