Opioid exposure among patients with hemophilia warrants ‘closer attention’
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Acute and chronic bleeding episodes are the most common complications associated with hemophilia.
Both soft tissue bleeds and recurring bleeds into joints often are accompanied by pain, which patients begin to experience at a young age. These patients appear more likely to be exposed to opioids than national data suggest, according to study results published in Haemophilia.
“I attended the American Academy of Pain Medicine Conference as part of the grant that supported my study and while I was there, I spoke to many different pain providers,” Skye J. Peltier, MPH, PA-C, physician assistant at the Center for Bleeding and Clotting Disorders at University of Minnesota Medical Center, said in an interview with Healio. “Surprisingly, most providers do not realize that pain is part of the hemophilia diagnosis.”
In the study, Peltier and colleagues evaluated exposure to opioids as a pain control measure among 183 adults and 135 children with hemophilia at two hemophilia treatment centers.
The researchers found that 56% of adults and 21% of children were exposed to opioids. These rates were significantly higher than those reported in the American Thrombosis & Hemostasis Network’s ATHNdataset and national population data from the CDC.
The researchers noted that severity of hemophilia appeared to be significantly predictive of opioid exposure among adults but not children. Most acute opioid prescriptions identified in the study did not originate from the hemophilia treatment centers.
Peltier spoke with Healio about her findings and their implications for future pain management of patients with hemophilia.
Question: What prompted you to study opioid exposure among patients with hemophilia?
Answer: In the context of the opioid epidemic, there was debate in the hemophilia community about the amount of exposure or risk to patients with hemophilia. Most literature on the topic was patient or provider survey data, and I wanted to look at objective prescription data. There was a perception that there was very little exposure, especially among pediatric patients, and I wanted to see if that was true.
Q: What did you find?
A: The adult findings supported the hypothesis that many patients with hemophilia are being treated for pain. As expected, we have a population of adults who are prescribed opioids on a chronic basis (21%). We were surprised by the high annual exposure rates of 38.3% to 49%; this was higher than general population annual exposure rates published by the CDC (11% to 27.9%). Clearly, our adult patients are exposed to opioids more frequently than the general population. This is something we need to pay closer attention to.
The pediatric data was certainly a wake-up call. Twenty-one percent of our kids were exposed to at least one opioid during the 3.5-year study period. Although many of these are for routine surgery, the rate is much higher than that reported by the CDC. Children aged 14 years and younger in our study had an annual exposure rate of 4.4% to 7.3%, compared with an age-and sex-matched CDC rate of 1.7% to 2.1%.
Q: Why do you think exposure to opioids was more prevalent than expected?
A: Most providers do not realize that pain is part of the hemophilia diagnosis. Each bleed into a joint or muscle causes acute pain. In addition, repeated bleeding events into a joint can result in severe joint destruction and chronic pain. This combination of acute and chronic pain can be quite difficult to manage. The second part of this problem is that most pain guidelines call for NSAIDs as first-line therapy. These drugs are contraindicated in hemophilia due to concern about increased bleeding due to platelet inhibition. This contraindication may result in higher exposure to opioids.
Q: Why do you think severity of hemophilia was a factor in adult opioid exposure but not in exposure among children?
A: This directly ties into the level of joint damage in adults from repeated bleeds. Although treatment for hemophilia has greatly improved in the last 20 years, we still have adults who have numerous joints affected and thus have chronic pain and need joint surgeries. Our goal for pediatric patients is no bleeds with our effective prophylactic therapy. We still see traumatic bleeds and need to deal with surgical events and opioid exposure in these situations.
Q. Your study showed most of opioid prescriptions were not written by hemophilia treatment centers. Does this mean that other physicians may need more education or information about managing pain among patients with hemophilia?
A: This was a surprising finding of our study and one we hope to address. We feel this ties back to the idea that NSAIDs are not to be used in patients with hemophilia. Although this is generally true, there are COX-2 inhibitors that result in minimal bleeding risk and could be safely prescribed. Hemophilia providers are aware of this and generally willing to prescribe these drugs. Another barrier to use of COX-2 inhibitors is the prior authorization often required by insurance. Surgeons and ED providers likely do not have the time or ability to pursue this option. So, although education may help, hemophilia providers could be more proactive in providing our patients with these medications for acute or postoperative pain.
Q: How much of a problem is opioid addiction in this patient population?
A: Although many hemophilia providers have patients who have experienced addiction, we do not have clear data on this issue. We have an opportunity to collect better data on medication use through the American Thrombosis and Hemostasis Network.
Q: Do you believe alternatives to opioids should be used for patients with hemophilia?
A: We have operated under a paradigm of avoidance of NSAIDs in hemophilia care. I feel there may be some situations where these drugs are safer than opioids and need to be considered. COX-2 inhibitors are a class of NSAIDs that are not platelet inhibitory. Other adjuvant pain treatments should be considered, as well. We have patients who have done well with other adjuvant pain medications or alternative therapies such as acupressure and acupuncture.
Q: What is the main takeaway of your study?
A: We cannot deny that patients of all ages with hemophilia have pain and at times exposure to opioids. Each exposure places a patient at risk for opioid-related morbidity and mortality. Those who care for patients with hemophilia need to take a more active role in pain management to limit these risks. Of special consideration is perioperative planning and coordination with nonhemophilia providers around pain management. When prescribing opioids, providers should follow current CDC prescribing guidelines and utilize state prescription drug monitoring programs, which support access to legitimate medical use of controlled substances while deterring drug abuse and diversion. – by Jennifer Byrne
Reference:
Peltier SJ, et al. Haemophilia. 2020;doi:10.1111/hae.13950.
For more information:
Skye J. Peltier, MPH, PA-C, can be reached at Suite 105, 2152 S. 7th St., Minneapolis, MN 55454; email: speltie1@fairview.org.
Disclosures: Peltier reports a CARE award from the American Thrombosis & Hemostasis Network, which enabled access to the ATHNdataset.
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