Table 2.
Risk of altered mental status, fall, and fracture among adults receiving hemodialysis with Medicare Part D coverage in 2011 by opioid dose and agent
| Altered Mental Status | Fall | Fracture | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Opioid exposure | Events (n) | Rate (per 100 PY) | Crude HR (95% CI) | Adjusted HR (95% CI) | Events (n) | Rate (per 100 PY) | Crude HR (95% CI) | Adjusted HR (95% CI) | Events (n) | Rate (per 100 PY) | Crude HR (95% CI) | Adjusted HR (95% CI) |
| Opioid dose | ||||||||||||
| Categorical | ||||||||||||
| None | 11,453 | 13 | 1.00 (Reference) | 1.00 (Reference) | 5659 | 6 | 1.00 (Reference) | 1.00 (Reference) | 3052 | 3 | 1.00 (Reference) | 1.00 (Reference) |
| Lower dosea | 3131 | 20 | 1.52 (1.46 to 1.58)b | 1.28 (1.23 to 1.34)b | 1534 | 10 | 1.50 (1.42 to 1.59)b | 1.28 (1.21 to 1.36)b | 848 | 5 | 1.53 (1.42 to 1.65)b | 1.44 (1.33 to 1.56)b |
| Higher dosec | 1074 | 29 | 2.17 (2.04 to 2.31)b | 1.67 (1.56 to 1.78)b | 453 | 12 | 1.83 (1.67 to 2.02)b | 1.45 (1.31 to 1.61)b | 251 | 6 | 1.87 (1.64 to 2.12)b | 1.65 (1.44 to 1.89)b |
| Continuous | ||||||||||||
| Total opioid dose (per 60 mg) | 1.50 (1.42 to 1.50)b | 1.29 (1.26 to 1.33)b | 1.34 (1.34 to 1.42)b | 1.04 (1.03 to 1.05)b | 1.42 (1.34 to 1.50)b | 1.04 (1.04 to 1.05)b | ||||||
| Opioid agent (per 60 mg) | ||||||||||||
| Recommended | ||||||||||||
| None | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | 1.00 (Reference) | ||||||
| Hydromorphone | 1.59 (1.34 to 1.77)b | 1.39 (1.23 to 1.57)b | 1.27 (1.06 to 1.59)b | 1.02 (1.01 to 1.04)b | 1.50 (1.13 to 1.87)b | 1.03 (1.02 to 1.04)b | ||||||
| Fentanyl | 1.42 (1.34 to 1.50)b | 1.18 (1.11 to 1.25)b | 1.27 (1.19 to 1.42)b | 1.06 (0.96 to 1.17) | 1.27 (1.13 to 1.50)b | 1.03 (0.90 to 1.18) | ||||||
| Methadone | 1.27 (1.13 to 1.42)b | 1.14 (1.01 to 1.29)b | 1.27 (1.00 to 1.50)b | 1.08 (0.92 to 1.28) | 1.13 (0.89 to 1.42) | 1.08 (0.87 to 1.34) | ||||||
| Use with caution | ||||||||||||
| Hydrocodone | 1.59 (1.50 to 1.68)b | 1.37 (1.29 to 1.47)b | 1.68 (1.59 to 1.87)b | 1.34 (1.27 to 1.41)b | 1.59 (1.42 to 1.77)b | 1.40 (1.32 to 1.48)b | ||||||
| Oxycodone | 1.34 (1.34 to 1.38)b | 1.31 (1.25 to 1.38)b | 1.19 (1.13 to 1.27)b | 1.13 (1.06 to 1.22)b | 1.34 (1.19 to 1.42)b | 1.25 (1.19 to 1.31)b | ||||||
| Tramadol | 1.97 (1.68 to 2.19)b | 1.48 (1.31 to 1.69)b | 1.87 (1.59 to 2.31)b | 1.42 (1.19 to 1.69)b | 2.19 (1.77 to 2.70)b | 1.65 (1.41 to 1.92)b | ||||||
| Avoid | ||||||||||||
| Codeine | 5.05 (3.14 to 8.20)b | 3.65 (2.12 to 6.30)b | 2.19 (0.94 to 5.05) | 1.57 (0.64 to 3.83) | 3.46 (1.27 to 9.69)b | 2.94 (1.00 to 8.66)b | ||||||
| Morphine | 1.59 (1.42 to 1.68)b | 1.40 (1.27 to 1.55)b | 1.19 (0.99 to 1.42)b | 1.15 (0.99 to 1.32) | 1.27 (0.94 to 1.59) | 1.11 (0.90 to 1.38) | ||||||
Results are adjusted for age, sex, race, duration on dialysis, network, body mass index, alcohol dependence, coronary artery disease, cancer, other cardiac disease, dysrhythmia, congestive heart failure, cerebrovascular disease, diabetes, drug dependence, opioid dependence, hypertension, inability to ambulate, inability to transfer, chronic obstructive pulmonary disease, peripheral vascular disease, tobacco dependence, liver disease, dementia, depression, seizures/epilepsy, osteoporosis, osteopenia, skilled nursing facility resident, medication burden, number of hypertensive medications, and concomitant medications. PY, person-year; HR, hazard ratio; 95% CI, 95% confidence interval.
Periods of lower-dose (0< average daily total dose ≤60 mg oral morphine equivalents) opioid exposure.
P value <0.05.
Periods of higher-dose (average daily total dose >60 mg oral morphine equivalents) opioid exposure.