Opioid use associated with increased risk of invasive pneumococcal disease

1. Researchers found a strong link between prescription opioid use and the risk for invasive pneumococcal disease (IPD).

2. The strongest link was present in individuals using formulations of opioids that were long-acting, highly potent, or utilized at a high dose.

Evidence Rating Level: 3 (Average)      

Study Rundown: Certain opioids possess immunosuppressive properties and have been shown to increase bacterial infection risk in animals. Such infections include those due to Streptococcus pneumoniae, which can cause IPD. The risks to humans, however, remain unclear. Researchers examined the hypothesis that the use of prescription opioids is an independent risk factor for IPD, which has a high rate of mortality. Through the use of a nested case-control study, the authors found that using opioids was strongly linked to a higher risk for IPD, especially when very potent or long-acting opioids were used. The authors suggest that these results should be taken into consideration when creating recommendations for preventing IPD. In light of this novel association between using opioids and IPD, the authors suggest that the risk, benefits, and formulation type should all be carefully considered when choosing an opioid for managing pain. Further research is needed to enable direct comparisons among separate opioids.

A strength of the study is the use of Tennessee Active Bacterial Core surveillance (ABCs) system data to find cases of IPD that were confirmed by a laboratory, which decreased the chance of misclassification. A limitation of the study is that opioid use was determined based on pharmacy prescription refills without observing actual use or accounting for illicit opioid use.

Click to read the study in Annals of Internal Medicine

Relevant Reading: Risk factors for invasive pneumococcal disease

In-Depth [case-control study]: Researchers used data from TennCare, which is a Tennessee Medicaid database, to conduct a nested case-control study. The study included 1 233 IPD patients ≥5 years of age serving as cases. These cases were matched to 24 399 controls based on age, date of diagnosis, and county of residence. The authors used the ABCs system to find laboratory-confirmed cases of IPD. The patient was considered to have IPD if a normally sterile site contained S. pneumoniae. Pharmacy prescription refills were used to determine opioid use. The authors compared the odds of existing use of opioids between case and control groups. Opioid use was also categorized by the characteristics of the opioids. Compared to controls, those in the case group had greater odds of being present users of opioids (adjusted odds ratio [aOR], 1.62). The link was greatest for opioids that were active for a long duration (aOR, 1.87), were highly potent (aOR, 1.72), or were utilized at a high dose (50 morphine milligram equivalents/day [MME/d] or greater). At a dose of 50 to 90 MME/d, the aOR was 1.71.  At a dose of ≥90 MME/d, the aOR was 1.75.

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