Deaths from opioid overdoses routinely claim headlines but nearly as many fatalities are caused each year by nonsteroidal anti-inflammatory drugs. Who's tracking trouble under the radar?
Given all the focus on opioids, it would be easy to assume that this is the only class of analgesics that we should be concerned about with regard to overprescription and misprescription. Two recent studies indicate, however, that we should be equally concerned about these issues in patients using nonsteroidal anti-inflammatory drugs (NSAIDs).
The first study investigated the use of NSAIDs by community-dwelling men age 70 years and older in Australia.1 It compared the patterns of NSAID use, both prescription and over-the-counter, with international and Australian guideline recommendations for their use in geriatric patients.
The study found that NSAIDs were being taken on a regular schedule, with a mean duration of almost 5 years, when in fact the guidelines recommend that they be used on an as-needed basis for the shortest time possible. It also found that only 25% of those using NSAIDs on a regular basis were given a prescription for proton pump inhibitors, though the guidelines recommend that their use be considered to reduce the risk of GI adverse effects.
Another interesting finding is that regular NSAID users are more likely to also take opioid analgesics, which indicates that these patients are not reducing their risk for opioid-related adverse events by taking NSAIDs instead.
This study was conducted in Australia so it is possible that the use of NSAIDs might be different in the United States. However, based on my own observations, I doubt that this is true. If anything, the fragmented way we provide medical care here, where patients often see multiple physicians with only limited coordination of care, makes it even more likely that no one is carefully monitoring NSAID use.
The risks associated with this fragmentation of care are exacerbated by the reality that patients entering their geriatric years are at an increased risk for cognitive impairment, which may make them less able to keep track of what medications they are taking. Since most NSAIDs are available without a prescription and are inexpensive when purchased over-the-counter, their misuse is not surprising. Even people who are cognitively intact may not be aware that they are taking different NSAIDs at the same time and may not exert the caution necessary to avoid taking excessive amounts and to recognize signs of potential adverse events.
The second study examined the association between NSAID use and atrial fibrillation (AF).2 Although previous studies have identified an increased risk of this condition with NSAID use, this current study is prospective, rather than retrospective.2 This allowed for the more accurate assessment of the onset of AF with NSAID use.
The study was conducted in the Netherlands and involved both men and women with a mean age of 68.5 years. Subjects were followed for a mean of 12.9 years.
The authors reported that using NSAIDs for 2 to 4 weeks and previous use of NSAIDs within the past 30 days both significantly increased the risk of AF. However, extended use beyond 30 days did not.
Although higher doses of the drug appeared to increase the risk, statistical significance was not reached. Use of the selective COX-2 inhibitors appeared to be most strongly associated with the increased risk of AF.
As to why shorter-term use of NSAIDs appeared to be more associated with AF than extended use, the authors speculate that it is possible that those who develop symptoms from short-term use are more likely to discontinue the medication than those who don’t experience any problems with it.
As with the use of opioids, the risks associated with NSAIDs shouldn’t prevent us from recommending their use when we feel that they may be beneficial for patients. However, we must closely monitor patients who are taking them and be attuned to recognizing problems associated with them, especially in the geriatric population.
Unfortunately, the Australian study indicates that when it comes to NSAIDs, physicians may not be as cautious about their use as they should be.
The debate over opioids in the United States has primarily focused on the laws regulating their use and whether they are too strict or too lenient, as well as the ways in which the laws affect overdose deaths. The issue of physician education has been sadly overlooked.
Approximately 16,900 deaths related to prescription opioid overdoses occur every year in the United States.3 Curiously, a similar number of deaths associated with NSAIDs has been commonly cited, although, in reality, the actual number is unknown and up for debate. For the most part, only deaths associated with GI bleeding and of patients using prescription NSAIDs have been examined.
There is no question that we should be concerned about problems related to the misuse of opioid drugs. However, that doesn’t mean we should ignore the risks associated with NSAIDs, which are easily obtained and cheap, and can be purchased without any legal restrictions.
1. Gnjidic D, Blyth FM, Le Couteur DG, et al. Nonsteroidal anti-inflammatory drugs (NSAIDs) in older people: prescribing patterns according to pain prevalence and adherence to clinical guidelines. Pain. 2014;155:1814-1820.
2. Krijthe BP, Heeringa J, Hofman A, et al. Non-steroidal anti-inflammatory drugs and the risk of atrial fibrillation: a population-based follow-up study. BMJ Open. 2014;4:e004059.
3. Prescription drug overdose in the United States: Fact sheet. Centers for Disease Control and Prevention. http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html. Accessed September 9, 2014.