Journal Article Annotations
2023, 2nd Quarter

Palliative Care

Annotations by R Garrett Key, MD
July, 2023

Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease

PUBLICATION #1 — Palliative Care

Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease

Amy W Johnson, Lilian Golzarri Arroyo, Neetu Mahendraker, Jack Hosty, Kurt Kroenke

Abstract: J Pain Symptom Manage. 2023 Apr;65(4):326-334.e2. doi: 10.1016/j.jpainsymman.2022.11.026. Epub 2022 Dec 8.

Context:
Patients with end-stage liver disease (ESLD) commonly experience pain and other symptoms that result in a poor quality of life. Few studies have examined opioid usage, adverse events (AEs), and other outcomes in ESLD patients receiving opioid analgesia.

Objectives:
This study aimed to compare outcomes in ESLD patients who received opioids to those who did not and to determine risk factors for AEs.

Methods:

This was a retrospective case-cohort study of 270 hospitalized patients with ESLD that used administrative and clinical data from the electronic medical record.

Results:
Two-thirds of patients with ESLD admitted during the study period received at least one opioid analgesic. Patients who received opioids presented with a greater number of liver related complications and higher rates of anxiety (32% vs. 17%, P= 0.007), had substantially worse initial and average pain scores (both P< 0.001), and received more palliative care consultations. The opioid group had somewhat more respiratory (22.2% vs. 11.1%, P= 0.02) and gastrointestinal (38.5% vs. 25.2%, P= 0.03) AEs, but no increase in CNS adverse events which included hepatic encephalopathy. Anxiety and disease severity (i.e., the number of liver related complications) but not opioid administration were risk factors for the number of AEs.

Conclusion:
Opioid administration was not an independent risk factor for the number of AEs in hospitalized patients with ESLD, whereas anxiety and more liver-related complications increased AE risk. Our findings suggest that opioids have an appropriate and reasonably safe role in alleviation of pain in patients with ESLD.

Keywords:
Cirrhosis, opioids; adverse events; analgesia; palliative care anxiety.

Annotation

The finding:
Opioid administration in patients hospitalized with end stage liver disease (ESLD) was not found to be associated with an increased rate of adverse events (AE), including CNS complications; the authors suggest that opioid analgesia is safe and appropriate for patients with ESLD and pain. However, anxiety and the number of liver-related complications were found to be associated with higher rates of AEs.

Strength and weaknesses:
The study included a relatively large cohort of 270 patients who were compared in a case-cohort design intended to allow for reasonable comparison between opioid treated and non-opioid exposed patients. The study was done at a single site and results may not be generalizable to other settings. The retrospective analysis makes it difficult to be certain of the indication for opioid use. Moreover, causality of adverse events is difficult to ascertain using this type of record review methodology.

Relevance:
C-L psychiatrists are often consulted to evaluate patients with ESLD who are also likely to have comorbid pain. Given the most common etiologies of ESLD—particularly alcohol use and chronic viral hepatitis—concerns about substance use and other psychiatric comorbidity are also common. There may be reluctance to employ opioids for the very common problem of pain in ESLD, and thus opioid analgesia may be unnecessarily withheld from people with ESLD. This review provides reasonable evidence that supports that opioid pharmacotherapy can be safely prescribed to help these vulnerable patients achieve a better quality of life.