Narcotic analgesics increase risk of falls and fractures among elderly

Falls and fractures among senior citizens have increased since rofecoxib (Vioxx®) was removed from the market in 2004, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in Chicago.

Narcotic analgesics (more commonly called narcotic pain killers), such as morphine and oxycodone, have long been used to treat pain. However, alternatives to this method of pain management have been identified, including the use of Cox-2 inhibitors, such as celecoxib (Celebrex®) and the now-recalled rofecoxib, which was removed from the market after being shown to increase the risk of heart attacks and strokes. With the recall of rofecoxib, many patients turned to the use of narcotic pain killers to manage pain from diseases like osteoarthritis (the most common joint disease affecting middle-age and older people. It is characterized by progressive damage to the joint cartilage—the cushioning material at the end of long bones—and causes changes in the structures around the joint).

Researchers recently studied whether the increase of narcotic pain killer use among senior citizens also meant an increase in falls and fractures. They pulled the medical records of over 10,000 people — who were over the age of 65 and had been diagnosed with osteoarthritis —and reviewed their records from 2001 through 2009. They noted if and when a patient had a fall or fracture as well as whether each patient fell into one of three categories of pain management: use of narcotic analgesics with the use of other, non-narcotic analgesics (such as nonsteroidal anti-inflammatory drugs); use of Cox-2 inhibitors alone or with other non-narcotic analgesics; and use of NSAIDs, other or no use of pain medication.

First, the researchers looked at the use of narcotic pain killers. Between 2001 and 2004, use jumped from eight percent to 20 percent, and it doubled to 40 percent by 2009. The use of Cox-2 inhibitors was low among these patients throughout the entire study period (eight percent). Next the researchers looked at falls and fractures and noted that less than one percent of these patients had a fall or fracture in 2001 but this increased four-fold (to 4%) by 2009, and this increase in falls and fractures was strongly associated with the increased use of narcotic pain killers.

"Overall there was a marked increase in the percentage of elderly patients who suffered a fall or fracture, and this increase paralleled the increased percentage of patients given narcotic pain relievers over this time period," explains Bruce N. Cronstein, MD; senior investigator in the study and Paul R. Esserman Professor of Medicine; director, NYU-HHC Clinical and Translational Science Institute; associate director for research, Department of Medicine; director, Division of Translational Medicine, New York University School of Medicine.

The research team also noted that, those who fell (regardless of what type of pain management they received) were older (in their 70s and 80s) and tended to be sicker than the individuals who did not suffer a fall or fracture. These findings made the researchers take a closer look at the effect of age and co-existing diseases and conditions on the risk for falls or fractures by comparing patients who fell to those who did not but who had similar health status and age.

"It is well known that as the elderly develop more chronic illnesses they become more frail and are more likely to fall and break a bone. We wanted to determine whether the risk of falls was associated with the use of narcotic pain relievers or whether physicians simply used narcotic pain relievers in older and sicker patients with chronic osteoarthritis," says Dr. Cronstein.

Patients who were taking narcotic pain killers were around four times more likely to suffer a fall than patients taking other types of pain relief for their OA - regardless of their health status or age. Ultimately, the study showed that falls and fractures increased among these patients when rofecoxib was removed from the market and narcotic pain killers were used in its place. These observations, lead researchers to believe that the recommendation for chronic pain treatment should be evaluated.

"The medical community only recently found that both COX2-selective and non-selective NSAIDS, including those available over the counter (e.g. ibuprofen), can increase the risk for heart attacks and other types of cardiovascular disease. Because of this discovery, some of these drugs — rofecoxib and valdecoxib — were taken off the market in late 2004 and 2005. Thereafter, there were marked changes in prescribing patterns for pain relievers to treat chronic diseases. We found that prescribing narcotic pain relievers before or instead of other types of pain relievers, as recommended in a number of practice guidelines from several professional groups, has the unintended consequence of increasing the risk for falling and fractures in the elderly. These results should lead to a reconsideration of these guidelines," concludes Dr. Cronstein.