Opioids may carry unique risks for patients on hemodialysis

A new analysis indicates that opioid pain medications may not be as safe for hemodialysis patients as recommendations suggest, and therefore, their use should be limited when possible. The analysis appears in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN).

Individuals with kidney failure who are undergoing hemodialysis frequently experience pain and often receive prescriptions for opioid medications. These patients may be especially vulnerable to opioid-related complications due to factors such as their kidneys' reduced ability to clear drugs from the body.

To evaluate the risks of opioid use in patients undergoing hemodialysis, Julie Ishida, MD, MAS (University of California, San Francisco and San Francisco VA Medical Center) and her colleagues examined information from 140,899 Medicare-covered adults in the United States who were receiving in-center hemodialysis in 2011.

Sixty-four percent of patients received an opioid prescription in 2011, and 11%, 5%, and 3% of patients had an episode of altered mental status, fall, and fracture requiring an emergency room visit or hospitalization, respectively. Opioid use was associated with higher risks for altered mental status, fall, and fracture in a dose-dependent manner. These risks were present even when patients were not prescribed high doses and when they received the types of opioid medications that have been recommended for use in patients undergoing hemodialysis.

"Opioid use in patients receiving hemodialysis, even at lower dosing, is not without risk, and the balance of risks and benefits in this population should be carefully considered," said Dr. Ishida. "Future research and strategies to predict and reduce the risks of opioid use in patients receiving hemodialysis are needed."

An accompanying Patient Voice editorial provides the perspective of David White, of Hillcrest Heights, Maryland, who remembers the first time a sharp large-gauge needle was inserted into his fistula for his first dialysis session, a procedure that was repeated over 1000 times over the next 6 years. Bracing himself for those painful "sticks" became part of his dialysis ritual. "Everyone's path to dialysis is different—the permutations are staggering—and the fact that each session can range from being a pleasant visit to an inconvenience to a traumatic experience or worse adds an additional level of complexity," he writes. "Pain management protocols can range from precise methodologies to 'one-size-fits-all' to woefully dismissive approaches, a sure recipe for patient harm." White points to the need for more pain management research as it relates directly to both clinical care planning and the quality of life for patients undergoing hemodialysis. He also stresses that opioids should be the last pain management option, not the first.