SLR - February 2020 - Kimberly A. Lockridge

Association of Opioid Use and Peripheral Artery Disease

Reference: Itoga NK, Sceats LA, Stern JR, Mell MW. Association of Opioid Use and Peripheral Artery Disease. J Vasc Surg. 2019. Oct;70(4): 1271-1279

Scientific Literature Review

Reviewed By: Kimberly A. Lockridge, DPM
Residency Program: West Penn Hospital – Pittsburgh, PA

Podiatric Relevance: This article is of relevance to podiatric surgeons because patients with peripheral arterial disease (PAD) can make up a significant portion of our patient population. Additionally, there has been an increase in opioid related deaths in recent years. In 2016, 40 percent of opioid related deaths were caused by prescription opioids. The purpose of this study was to evaluate the association between PAD and opioid use to determine if patients with PAD are at a high risk for high opioid use. This study also assessed the effect of PAD treatment, which includes open revascularization, above the ankle amputation and percutaneous revascularization, on opioid use.

Methods: This retrospective cohort study utilized the Truven Health MarketScan database (a national private insurance database) to identify patients with PAD and critical limb ischemia (CLI) from 2007 to 2015. A diagnosis of CLI was given when patient had rest pain, gangrene or ulcers. A total of 178,880 PAD patients were identified, of whom 63,400 (35 percent) had CLI. High opioid use was the primary outcome, which was defined as ≥ two opioid prescriptions within a one-year interval. Secondary outcomes assessed patient demographic data and comorbidities and utilized multivariable analysis to identify risk factors for high opioid use. PAD patients who underwent PAD-related procedures were compared to those who did not undergo procedures. A separate analysis was performed for CLI patients.

Results: An average of 24.7 percent of PAD patients met high opioid use criteria, with an average of 5.9 ± 5.5 opioid prescriptions received per year for high opioid users. The rate of high opioid use increased to 29.6 percent after a new diagnosis of PAD was made. This increase was even greater in patients with a new diagnosis of CLI (34.5 percent) After multivariable regression analysis, pain and illicit drug use were found to be highest risk for high opioid use. High opioid users were more likely to be female, younger and have more comorbidities. CLI diagnosis was found to be independently associated with a higher risk of high opioid use. High opioid use increased from 26 percent to 30 percent after PAD treatment, despite excluding opioid prescriptions written within 90 days of a procedure. These post-procedural prescriptions were only 4.9 percent of all opioid prescriptions written during follow-up.

Conclusions: This study showed PAD patients are at risk for high opioid use. Physicians should have heightened awareness when treating these patients, especially patients with CLI and those undergoing a PAD procedure since they are at an even higher risk. The post-procedural increase of high opioid use may lead to dependence and long-term use. All physicians should be aware of these potential outcomes and continue to be mindful with prescribing opioids after PAD interventions to reduce the risk of long-term use.  

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