Which painkillers are safest for the elderly?

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NEW YORK (Reuters Health) - A type of pain medicine long believed to be relatively safe for older adults appears to come with more risks than other, supposedly riskier, painkillers, new study findings report.

The authors found that people on opioids, a class of pain drugs that includes morphine and codeine, had a higher risk of fractures, cardiovascular problems such as heart attack or stroke, hospitalizations, and death relative to other types of pain medication, including over-the-counter drugs.

And even though doctors have long believed that all opioids have generally the same risks, the authors, led by Dr. Daniel Solomon at Brigham and Women's Hospital in Boston, found some appeared to carry higher risks than others.

"People have somehow believed opioids to be safer," Solomon told Reuters Health. "Our data suggest that is not always the case."

Ironically, doctors have often prescribed opioids instead of less powerful pain medications out of concern of side effects. For instance, pain drugs known as non-steroidal anti-inflammatory drugs, or NSAIDs, are associated with stomach problems such as ulcers and cardiovascular disease.

When scientists discovered one subset of NSAIDs, the so-called selective COX-2 inhibitors, the hope was they would lower the risk of ulcers among chronic users of NSAIDs, such as people with rheumatoid arthritis.

But most COX-2 inhibitors ran into safety issues a few years after their approval, and now only Pfizer's Celebrex (celecoxib) remains on the U.S. market. Other NSAIDs include naproxen, ibuprofen, ketoprofen and aspirin.

The latest findings now suggest opioids may not be any safer -- and may even be more harmful.

To compare the safety of opioids to NSAIDs, Solomon and his team looked at data collected from 4,280 elderly people receiving opioids for arthritis pain, 4,280 matched patients who were prescribed over-the-counter NSAIDs such as ibuprofen, and 4,280 given a prescription for a COX-2 inhibitor.

They found opioid-users had more than four times the risk of fractures compared to people using over-the-counter medications, and a higher risk of cardiovascular disease, hospitalization, and death.

Specifically, during the study period, 105 developed cardiovascular problems on over-the-counter pain medicine users, versus 196 among opioid users and 208 among COX-2 inhibitor users.

People taking opioids experienced more than 160 fractures, which occurred less than 50 times among both users of COX-2s and over-the-counter drugs.

They were also equally likely to report stomach bleeding, a sign of ulcers, as those taking over-the-counter medicines, the drugs normally linked to stomach problems.

To compare various opioids to each other, Solomon and his team reviewed data collected from an equal number of older adults (more than 6,000 in each category), each taking one of five opioid drugs for pain.

People on codeine had a 60-percent higher risk of cardiovascular problems within half a year of getting the prescription, experiencing nearly 130 such events. Relative to people taking hydrocodone, among whom 255 fractures occurred, those taking the drugs tramadol and propoxyphene had a lower risk of fractures, reporting only 64 and 162, respectively.

People taking oxycodone and codeine had more than twice the risk of dying within 30 days following the prescription, also relative to hydrocodone-users.

Both sets of findings appear in the Archives of Internal Medicine.

This is not the first indication that opioids come with risks -- last month, the company that makes the opioid propoxyphene pulled the drug from the market because it can cause fatal heart rhythms.

Despite the risks, Solomon said he continues to "carefully" prescribe opioids, while explaining the risks that come with these prescriptions to patients.

These medicines still do have use, agreed Dr. Patrick O'Connor at the Yale University School of Medicine in New Haven, Connecticut, who wrote an accompanying editorial. Because they are much stronger than NSAIDs, they will likely remain invaluable to people with particularly painful conditions, such as a compression fracture of the spine.

But even here, people should proceed cautiously, perhaps selecting first the least potent opioid -- such as tramadol, associated with a lower fracture risk -- and be monitored.

"When a pain medication is selected, it needs to be done thoughtfully, with a detailed discussion" of the benefits and risks of any given drug, O'Connor told Reuters Health.

SOURCE: http://link.reuters.com/muz32r and http://link.reuters.com/nuz32r Archives of Internal Medicine, December 13/27, 2010.

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