What Pain Med Causes the Most Cardiovascular Death?
Which therapy is associated with the biggest increase in risk of cardiovascular death among patients battling moderate-to-severe chronic pain?
a. oxycodone
b. pregabalin
c. gabapentin
d. amitriptyline
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Answer: a
Dr. Wayne Ray, a professor of health policy at Vanderbilt University School of Medicine, led a recent review of nearly 23,000 new opioid prescriptions written to treat back and musculoskeletal pain. The study showed opioids increased risk of all-cause death by 64% and cardiovascular death by 65%, according to Dr. Ray. Although the current national discourse focuses on the danger of opioid overdose, Dr. Ray said the risk of cardiovascular death is more prevalent in most patient populations because chronic opioid use exacerbates obstructive and central sleep apnea, which can cause heart arrhythmias. He said the study’s findings support the Centers for Disease Control and Prevention’s recommendation to avoid using opioids as the first-line treatment of chronic pain and increases the urgency to limit the use of long-acting opioids to patients in whom clinical benefits outweigh the risk of harm.
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Dr. Ray said over-the-counter nonsteroidal anti-inflammatory drugs are best for less severe chronic pain and non-opioid alternatives such as the anticonvulsants pregabalin and gabapentin and the low-dose cyclic antidepressant amitriptyline are relatively safe alternatives for moderate-to-severe chronic pain, although they can also cause side effects such as dizziness, somnolence, nausea, peripheral oedema, and gait disturbance. The bottom line, said Dr. Ray: Long-acting opioids should be avoided whenever possible to manage chronic pain, especially in patients at high risk for cardiovascular disease caused by diabetes or history of myocardial infarction. When long-acting opioids must be prescribed, advised Dr. Ray, the lowest possible dose should be used.
Reference
Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer. JAMA. 2016;315(22):2415-2423.
