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Medication Increases the Risk of Recurrent Falls

Apr 18, 2017

Researchers have found that low-extremity osteoarthritis (OA) patients who take opioids or antidepressants have an increased risk of repeated falls. Compared to individuals not taking any analgesics (painkillers), knee OA patients who used opioids had a 22 percent increased risk of recurrent falls, reports MedPage Today.

Research on Recurrent Falls

Wei-Hsuan Lo-Ciganic, PhD, of the University of Arizona College of Pharmacy, and colleagues reported in Osteoarthritis and Cartilage, this is the first study to examine the risk of recurrent falls with arthritis analgesics. Researchers also found that OA patients taking antidepressants had a 25 percent higher probability of falling two or more times.

"Recurrent falls may be more clinically meaningful than a single fall, since multiple falls may signal physical and cognitive deficits, as well as increased risk for subsequent falls and mobility decline in older adults," the researchers wrote.

In a longitudinal cohort study, the researchers studied 4,231 patients from the Osteoarthritis Initiative (OAI). This type of study sample a cohort (a group of people who share a defining characteristic, such as having experienced a common event in a particular period, such as birth or graduation) and perform cross-section observations at intervals through time, according to MedPage Today.

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Participants in the Study

Participants included people from 45 to 70 years of age with or at risk of knee OA in four U.S. cities from 2004 to 2006. The group consisted primarily of women (58.4 percent). The study involved the analgesic and nutraceutical (dietary supplement) use in OAI participants for 36 months and recurrent falls for 48 months.

More than 80 percent of the opioid group participants used multiple pain medications, as the authors had anticipated. Because OA patients typically take multiple pain medications, the researchers classified participants into six exclusive groups, classified by the analgesic potency and central nervous system effects of the medications they used: opioids, oral or transdermal; antidepressants in absence of opioids; other prescription pain medication including NSAIDs (non-steroidal anti-inflammatory drugs), salicylates, or triptans in absence of opioids or antidepressants; over-the-counter NSAIDs or acetaminophen (a non-aspirin pain reliever such as Tylenol), in absence of prescription drugs; nutraceuticals like chondroitin, glucosamine, methylsulfonylmethane, or S-adenosylmethionine; or no pain medication.

Researchers' Findings

After adjusting for relevant variants such as depression and pain severity, the authors saw that participants who used opioids or antidepressants had a significantly higher rate of recurrent falls.

"Our findings were generally consistent with prior reports that suggest opioids and antidepressants increase risk for falls in older adults," they said. "Clinical management of OA pain with opioids or antidepressants in older patients at risk of falls warrants caution."

These results did not surprise Lo-Ciganic and colleagues, since opioids may cause drowsiness, dizziness, and cognitive impairment and antidepressants may contribute to impaired alertness and neuromuscular function, sedation, confusion, and insomnia, reports MedPage Today.

As the researchers expected, opioids and a higher number of combination medications were associated with severe pain. "Notably, participants in the opioids and antidepressants groups had higher proportions of concurrent use of other psychotropic medications, (e.g., benzodiazepines), exposing them to cumulatively higher risks of falls," the researchers wrote.

While other prescription pain medications decreased from 16.7 percent to 11.9 percent, opioid use increased from 2.7 percent to 3.6 percent, over the 36-month period. Women used antidepressants and opioids more than men. Patients taking opioids had higher comorbidity (existing simultaneously with and usually independently of another medical condition), increased significant depression symptoms, and poor self-reported health.

The researchers also observed that half of the participants took prescription or over-the-counter NSAIDs or acetaminophen, the recommended initial analgesic for OA pain. They suggested that a trend toward fewer non-opioid medications might reflect increased awareness concerning NSAIDs' adverse gastrointestinal, renal (kidney), and cardiovascular effects. The researchers added that the removal of rofecoxib (brand name Vioxx) and valdecoxib (brand name Bextra) from the U.S. market may have contributed to this trend.

The study authors also noted that one-third of patients consumed nutraceuticals, despite the lack of medical standards or guidelines supporting their use, MedPage Today reports.

The large sample size and ability to adjust for confounders or variables such as pain severity and depression, were some of the strengths of this study.

Limitations of the study included the fact that recurrent falls were self-reported, after the fact. "The true rate may be underestimated, compared with rates ascertained by more frequent prospective monitoring," the authors said.

"Given the overall infrequent opioid use (less than 5 percent) in our sample, we do not have sufficient power to stratify our analyses by those on opioid monotherapy versus [those] on opioids with other analgesics," researchers noted.

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