Skip to main content
Log in

Relationship of Opioid Use and Dosage Levels to Fractures in Older Chronic Pain Patients

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Opioids have been linked to increased risk of fractures, but little is known about how opioid dose affects fracture risk.

Objective

To assess whether risk of fracture increases with opioid dose among older patients initiating sustained use of opioids for chronic non-cancer pain.

Design

A cohort study that uses Cox proportional hazards models to compare fracture risk among current opioid users vs. persons no longer using opioids.

Participants

Members of an integrated health care plan (N = 2,341) age 60 years and older who received 3+ opioid prescriptions within a 90-day period for chronic, non-cancer pain between 2000 and 2005.

Measurements

Time-varying measures of opioid use and average daily dose in morphine equivalents were calculated from automated data. Fractures were identified from automated data and then validated through medical record review.

Results

Compared with persons not currently using opioids, opioid use was associated with a trend towards increased fracture risk (1.28 (95% CI (0.99, 1.64 )). Higher dose opioid use (≥50 mg/day) was associated with a 9.95% annual fracture rate and a twofold increase in fracture risk (2.00 (95% CI (1.24, 3.24)). Of the fractures in the study cohort, 34% were of the hip or pelvis, and 37% were associated with inpatient care.

Conclusions

Higher doses (≥50 mg/day) of opioids for chronic non-cancer pain were associated with a 2.00 increase in risk of fracture confirmed by medical record review. Clinicians should consider fracture risk when prescribing higher-dose opioid therapy for older adults.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

References

  1. Zerzan JT, Morden NE, Soumerai S, et al. Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs, 1996 to 2002. Med Care. 2006;44:1005–10.

    Article  PubMed  Google Scholar 

  2. Caudill-Slosberg M, Schwartz L, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain. 2004;109:514–9.

    Article  PubMed  Google Scholar 

  3. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349(20):1943–53.

    Article  CAS  PubMed  Google Scholar 

  4. Martell BA, O’Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2):116–27.

    PubMed  Google Scholar 

  5. Ballantyne JC, Shin NS. Efficacy of opioids for chronic pain: a review of the evidence. Clin J Pain. 2008;24(6):469–78.

    Article  PubMed  Google Scholar 

  6. Noble M, Tregear SJ, Treadwell JR, Schoelles K. Long-term opioid therapy for chronic noncancer pain:a systematic review and meta-analysis of efficacy and safety. J Pain Symptom Manage. 2008;35:214–28.

    PubMed  Google Scholar 

  7. Kelly J, Cook S, Kaufman D, Anderson T, Rosenberg L, Mitchell A. Prevalence and characteristics of opioid use in the US adult population. Pain. 2008;138:507–13.

    Article  Google Scholar 

  8. Paulose-Ram R, Hirsch R, Dillon C, Losonczy K, Cooper M, Ostchega Y. Prescription and non-prescription analgesic use among the US adult population: results from the third National Health and Nutrition Examination Survey (NHANES III). Pharmacoepidemiol Drug Saf. 2003;12:315–26.

    Article  PubMed  Google Scholar 

  9. Sullivan MD, Edlund MJ, Zhang L, Unutzer J, Wells KB. Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med. 2006;166:2087–93.

    Article  PubMed  Google Scholar 

  10. Braithwaite RS, Col N, Wong J. Estimating hip fracture morbidity, mortality and costs. JAGS. 2003;51:364–70.

    Article  Google Scholar 

  11. Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with the use of morphine and opiates. J Intern Med. 2006;260:76–87.

    Article  CAS  PubMed  Google Scholar 

  12. Ensrud K, Blackwell T, Mangione C, et al. Central nervous system active medications and risk for fractures in older women. Arch Intern Med. 2003;163:949–57.

    Article  PubMed  Google Scholar 

  13. Vestergaard P. Pain-relief medication and risk of fractures. Curr Drug Saf. 2008;3:199–203.

    Article  CAS  PubMed  Google Scholar 

  14. Shorr RI, Griffin MR, Daugherty JR, Ray WA. Opioid analgesics and the risk of hip fracture in the elderly: codeine and propoxyphene. J Gerontol. 1992;47:M111–5.

    CAS  PubMed  Google Scholar 

  15. Guo Z, Wills P, Viitanen M, Fastborn J, Winblad B. Cognitive impairment, drug use, and the risk of hip fracture in persons over 75 years old: a community-based prospective study. Am J Epidemiol. 1998;148:887–92.

    CAS  PubMed  Google Scholar 

  16. Kamal-Bahl S, Stuart B, Beers M. Propoxyphene use and risk for hip fractures in older adults. Am J Geriatr Pharmacother. 2006;4:219–26.

    Article  CAS  PubMed  Google Scholar 

  17. French D, Campbell R, Spehar A, Rubenstein LZ, Branch L, Cunningham F. National outpatient medication profiling: medications associated with outpatient fractures in community-dwelling elderly veterans. Br J Clin Pharmacol. 2007;63(2):238–44.

    Article  PubMed  Google Scholar 

  18. Spector W, Shaffer T, Potter E, Correa-de-Araujo R, Rhona Limcangco M. Risk factors associated with the occurrence of fractures in U.S. nursing homes: resident and facility characteristics and prescription medications. JAGS. 2007;55:327–33.

    Article  Google Scholar 

  19. Abrahamsen B, Brixen K. Mapping the prescriptiome to fractures in men—a national analysis of prescription history and fracture risk. Osteoporosis Int. 2008; Aug 9 [Epub ahead of print].

  20. Takkouche B, Montes-Martinez A, Gill S, Etminan M. Psychotropic medications and the risk of fracture. Drug Saf. 2007;30(2):171–84.

    Article  PubMed  Google Scholar 

  21. Von Korff M, Saunders K, Ray T, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24(6):521–7.

    Article  PubMed  Google Scholar 

  22. Saunders K, Davis R, Stergachis A. Group Health Cooperative. In: Strom B, ed. Pharmacoepidemiology. West Sussex: John Wiley and Sons; 2005:223–39.

    Google Scholar 

  23. Fishman P, Goodman M, Hornbrook M, et al. Risk adjustment using automated pharmacy data: the Rx Risk Model. Med Care. 2003;41:84–99.

    Article  PubMed  Google Scholar 

  24. Romano PS, Roos L, Jollis J. Further evidence concerning the use of a clinical comorbidity index with ICD-9-CM administrative data. J Clin Epidemiol. 1993;46:1085–90.

    Article  Google Scholar 

  25. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. N Engl J Med. 1995;332:767–73.

    Article  CAS  PubMed  Google Scholar 

  26. Therneau TM, Grambsch PM. Modeling Survival Data: Extending the Cox Model. New York: Springer-Verlag; 2000.

    Google Scholar 

  27. Cumming R. Epidemiology of medication-related falls and fractures in the elderly. Drugs Aging. 1998;12:43–53.

    Article  CAS  PubMed  Google Scholar 

  28. Wagner AK, Zhang F, Soumerai S, et al. Benzodiazepine use and hip fractures in the elderly: who is at greatest risk? Arch Intern Med. 2004;164:1567–72.

    Article  PubMed  Google Scholar 

  29. Kinjo M, Setoguchi S, Schneeweiss S, Solomon D. Bone mineral density in subjects using central nervous system-active medications. Am J Med. 2005;118:1414.e7–1414.e12.

    Article  Google Scholar 

  30. Haentjens P, Lamraski G, Boonen S. Costs and consequences of hip fracture occurrence in old age: an economic perspective. Disabil Rehabil. 2005;27:1129–41.

    Article  CAS  PubMed  Google Scholar 

  31. AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc (in press).

  32. Barkin R, Barkin S, Barkin D. Perception, assessment, treatment and management of pain in the elderly. Clin Geriatr Med. 2005;21:465–90.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This research was supported by a grant to Dr. Michael Von Korff from the National Institute of Drug Abuse [DA022557].

Conflict of Interest Statement

Ms. Saunders owns stock in for-profit companies. Dr. Von Korff owns stock in for-profit companies and has received a grant from Johnson & Johnson. In the past three years Dr. Sullivan has received grants from Wyeth, Eli Lilly and Company, Aetna, and Ortho McNeil and has consulted for Eli Lilly and Company. Otherwise, the authors report no conflicts of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Kathleen W. Saunders JD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Saunders, K.W., Dunn, K.M., Merrill, J.O. et al. Relationship of Opioid Use and Dosage Levels to Fractures in Older Chronic Pain Patients. J GEN INTERN MED 25, 310–315 (2010). https://doi.org/10.1007/s11606-009-1218-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-009-1218-z

KEY WORDS

Navigation