Almost 23,000 patients prescribed both long-acting opioids versus anticonvulsants and tricyclics, used for pain, were followed, and total mortality, over and above overdose deaths, was assessed. The alternatives to opioids were mainly gabapentin, pregabalin, carbamazepine, and tricyclics, mainly Elavil. Doses of greater than 150 mg of Elavil were excluded. These patients were treated for noncancer pain, mainly low back pain.

The opioid treated group had 1-1/2 to 2 times excess mortality compared to the other groups. This mortality was seen mainly in the first 6 months. Two-thirds of the excess deaths were unrelated to unintentional overdose. One-half were cardiovascular. Patients being treated for palliative or end-of-life care were excluded.

The authors believe that the main cause may be the fact that opioids cause or worsen obstructive and central sleep apnea, and these patients have increased incidence of nocturnal arrhythmias, myocardial infarction, or sudden death. They further stated that for some individual patients, the therapeutic benefits of opioids may outweigh the increase in mortality risk.

In the same journal, a second study beginning on page 2459 by J.C. Ballantyne, MD, looked at the efficacy and tolerability of long-term treatment with opioids for chronic low back pain. Thirteen trials with almost 3500 patients were identified. At least half withdrew for adverse effects or lack of efficacy. There was “moderate quality evidence” that opioids reduce pain in the short-term but no evidence to support long-term use for low back pain.

See JAMA, 2016, page 2415.

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