Pritchard Kevin T, Yang Chun-Ting, Chen Qiaoxi, Zhang Yichi, Wilkins James M, Kim Dae Hyun, Lin Kueiyu Joshua
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Division of Geriatric Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Massachusetts, USA.
J Am Geriatr Soc. 2025 Mar;73(3):737-749. doi: 10.1111/jgs.19290. Epub 2024 Dec 1.
Adults with Alzheimer's disease and Alzheimer's disease related dementias (ADRD) or frailty are susceptible to fractures. Opioid analgesics are frequently prescribed after fractures. Documenting post-fracture opioid discontinuation rates and predictors of discontinuation among adults with ADRD or frailty can inform clinical practice, identify potential disparities, and improve pain management guidelines. The objective of this paper was to investigate opioid discontinuation in opioid-naïve older adults who used opioids after an acute fracture.
This retrospective cohort study included opioid-naïve Medicare fee-for-service beneficiaries (N = 33,027) ≥65 years of age who filled an opioid prescription within 30 days of a vertebral, lower extremity, or upper extremity fracture from 2013 to 2018. Beneficiaries were classified according to ADRD (yes/no) and frailty (yes/no) status using validated claims-based algorithms. The primary outcome was opioid discontinuation, defined as a 30-day supply gap. We estimated discontinuation rates with the Kaplan-Meier method and identified predictors of opioid discontinuation using Cox proportional hazards regression.
The 30-day opioid discontinuation rate was similar among non-frail beneficiaries without ADRD (81% [95% CI, 80%-81%]) and those who were non-frail with ADRD (83% [81%-84%]). Comparatively, 30-day discontinuation rates were lower among those with frailty and ADRD (76% [75%-77%]) and those with frailty alone (77% [75%-78%]). After adjusting for sociodemographic characteristics, health status, healthcare utilization, and calendar year, beneficiaries with both ADRD and frailty (HR, 0.90 [0.87-0.93]) and those with frailty alone (HR, 0.85 [0.82-0.89]), but not those with ADRD alone (HR, 1.06 [1.01-1.10]), were less likely to discontinue opioids compared with those without ADRD or frailty.
Our findings suggest that frailty, but not ADRD, was associated with a lower likelihood of opioid discontinuation among older adults who initiated opioids after an acute fracture. Further research is needed to understand how opioid deprescribing practices depend on patient and provider preferences.
患有阿尔茨海默病及与阿尔茨海默病相关的痴呆症（ADRD）或身体虚弱的成年人易发生骨折。骨折后常开具阿片类镇痛药。记录ADRD或身体虚弱的成年人骨折后阿片类药物停药率及停药预测因素可为临床实践提供参考，识别潜在差异，并改进疼痛管理指南。本文的目的是调查急性骨折后使用阿片类药物的未使用过阿片类药物的老年人的阿片类药物停药情况。
这项回顾性队列研究纳入了2013年至2018年期间年龄≥65岁、未使用过阿片类药物的医疗保险按服务收费受益人（N = 33,027），这些人在椎骨、下肢或上肢骨折后30天内开具了阿片类药物处方。使用经过验证的基于索赔的算法，根据ADRD（是/否）和身体虚弱（是/否）状态对受益人进行分类。主要结局是阿片类药物停药，定义为30天的供应缺口。我们用Kaplan-Meier方法估计停药率，并使用Cox比例风险回归确定阿片类药物停药的预测因素。
在没有ADRD的非虚弱受益人（81% [95% CI，80%-81%]）和患有ADRD的非虚弱受益人（83% [81%-84%]）中，30天阿片类药物停药率相似。相比之下，身体虚弱且患有ADRD的人（76% [75%-77%]）和仅身体虚弱的人（77% [75%-78%]）的30天停药率较低。在调整了社会人口统计学特征、健康状况、医疗保健利用和日历年之后，与没有ADRD或身体虚弱的人相比，同时患有ADRD和身体虚弱的受益人（HR，0.90 [0.87-0.93]）和仅身体虚弱的受益人（HR，0.85 [0.82-0.89]）停用阿片类药物的可能性较小，但仅患有ADRD的人（HR，1.06 [1.01-1.10]）并非如此。
我们的研究结果表明，在急性骨折后开始使用阿片类药物的老年人中，身体虚弱而非ADRD与阿片类药物停药可能性较低有关。需要进一步研究以了解阿片类药物减停做法如何取决于患者和提供者的偏好。
