Assessment of Prescription Analgesic Use in Older Adults With and Without Chronic Kidney Disease and Outcomes

Abstract

Importance: Pain is a common symptom among patients with kidney disease. However, little is known about use of analgesics among patients aged 65 years or older with chronic kidney disease (CKD) who do not receive dialysis treatment.

Objective: To assess national trends and geographic variations in use of opioids and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) in older adults with and without CKD in the US (2006-2015) and examine associations between use of opioids and patient outcomes.

Design, setting, and participants: This cohort study used the 5% Medicare claims data (2005-2015) to select 10 retrospective annual cohorts of Medicare Part D beneficiaries aged 65 years and older from 2006 to 2015 and a retrospective longitudinal cohort. Data were analyzed in August 2019.

Exposures: CKD status and other comorbidities identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes.

Main outcomes and measures: Analgesic use was measured by overall use (proportion of ever used opioids/NSAIDs), long-term use (prescribed >90 days), and cumulative use (total annual days' supply). Patient outcomes included progression to end-stage kidney disease (ESKD) and all-cause mortality.

Results: A total of 6 260 454 beneficiaries (9.6% identified with CKD by claims) were selected in the annual cohorts and 649 339 beneficiaries (8.3% identified with CKD) were selected in the longitudinal cohort. There was significant growth in opioid use (31.2%-42.4%) and NSAID use (10.7%-16.6%) among patients aged 65 years and older with CKD from 2006 to 2015. Long-term use of opioids increased during 2006 to 2014 (25.8%-36.7%) but decreased through 2015 at 35.6%, while long-term use of NSAIDs remained stable. Opioid use was higher in patients with CKD, particularly CKD stages 4 to 5 (odds ratio [OR], 1.35; 95% CI, 1.33-1.37; P < .001) compared with non-CKD. NSAID use was lower in patients with CKD stages 4 to 5 (OR, 0.55; 95% CI, 0.54-0.56; P < .001). Substantial geographic variations in analgesic use were observed across states (opioid use in CKD: 24.7%-54.3%; NSAID use in CKD: 11.2%-20.8%, 2012-2015). Opioid use was associated with progression to ESKD (hazard ratio [HR], 1.10; 95% CI, 1.04-1.16; P = .001) and death (HR, 1.19; 95% CI, 1.18-1.20; P < .001) independent of CKD status and other covariates. There was an inverse association between NSAID use and death (HR, 0.84; 95% CI, 0.83-0.85; P < .001).

Conclusions and relevance: Among Medicare patients with CKD, use of prescription analgesics, both opioid and NSAID, increased from 2006 to 2015. Optimizing pain management in a complex condition such as kidney disease should remain a priority for clinicians and researchers alike.

Figure 1.. Trends in Use of Opioids and Prescription Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) by Chronic Kidney Disease (CKD) Status, Annual Cohort 2006-2015

A, Opioids were prescribed to 31.2% of older patients with CKD in 2006, peaking at 44.1% in 2013 and then decreasing each year through 2015 (42.4%). B, Overall use of prescription NSAIDs increased from 10.7% in 2006 to a peak of 17.4% in 2013, with a gradual decrease to 16.6% in 2015. C, The proportion of prescribed opioids for more than 90 days was higher in the CKD users compared with the non-CKD users (35.6% vs 29.1%, 2015). D, Approximately one-third of CKD users had received prescription NSAIDs for more than 90 days, varying from 23.2% in CKD stages 4-5 to 33.2% in CKD stages 1-2 (2015).

Figure 2.. Changes in Proportion of Prescribed Opioids and Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Among Patients With and Without Chronic Kidney Disease (CKD), 2012-2015