Q&A: Patients with NAFLD-related cirrhosis, high BMI, psychiatric disease likely to use opioids
Opioid use was more common in patients with nonalcoholic fatty liver disease with cirrhosis, higher BMI and psychiatric disease, according to a study published in Digestive Diseases.
Healio Gastroenterology spoke with Andrew M. Moon, MD, advanced/ transplant hepatology at the University of North Carolina, about the TARGET-NASH study looking at opioid use in 3,474 patients with NAFLD.
Healio: What was the purpose of the study?
Moon: We knew that the burden of NAFLD was huge in the United States and we knew from clinical experience that patients with this condition experience painful comorbidities. These painful comorbidities limit physical activity. This is really important for our patients given that physical activity is a cornerstone in the treatment of the disease. NSAIDs like ibuprofen are contraindicated in patients with cirrhosis and acetaminophen is often avoided in this population given perceived safety concerns. We knew from previous studies that opioid use is very common among patients with cirrhosis. Opioids have been shown to increase the risk of hepatic encephalopathy in patients with cirrhosis and decrease health related quality of life. Opioid related sedation may also inhibit physical activity. Given these concerns, we were really interested in looking at opioid use among patients with NAFLD.
In this cross-sectional study, we identified patients with NAFLD disease based on either liver biopsy or pragmatic definitions. We determined whether they had opioid prescriptions within the 1-year prior to enrollment in the cohort and then assessed for potential risk factors that may predict opioid prescriptions.
Healio: What were the results?
Moon: Approximately 20% of patients with NAFLD were prescribed opioids. About one-quarter of patients with cirrhosis from NAFLD reported opioid use. Opioid use was twice as common among patients with NAFLD cirrhosis compared with NAFLD without signs of steatohepatitis. Other factors associated with an increased risk for opioid use included higher BMI, painful comorbidities and psychiatric disease.
Healio: Do you think the result will impact the use of prescription opioids in NAFLD?
Moon: Yes. It will bring increased attention to this really important topic and hopefully it will prompt providers to reassess every opioid prescription that they are providing their patients with NAFLD. The identification of potential risk factors for opioid use may be used to identify patients who may benefit from early intervention to prevent pain from developing and prevent future opioid use. There’s some really interesting research demonstrating that early physical therapy may prevent future opioid use. It may be that patients who have NAFLD with a higher BMI, with osteoarthritis, psychiatric disease may benefit from that early physical therapy to prevent future opioid use. It is also important to identify and treat anxiety and depression, which are common in patients with liver disease.
Healio: What is the take-home message of the study?
Moon: Opioid use was relatively common among patients with NAFLD. It was more common among patients with more severe liver disease, anxiety and depression. Given the well-established safety concerns associated with opioid treatment, use of non-pharmacological options and safe non-opioid analgesics such as low dose acetaminophen should be considered for the treatment of pain in patients with NAFLD.
Healio: What is the next step in research?
Moon: A well-designed prospective study to better understand the association between these risk factors and future opioid use and better understand how opioid use impacts the quality of life and patient outcomes in patients with NAFLD. TARGET-NASH is a perfect example of a well-designed prospective cohort study that will allow us to answer these important questions.
Many patients who have NAFLD struggle with these painful comorbidities and there are a lot of people in the community saying acetaminophen should never been used when we know that low-dose acetaminophen is very safe. NSAIDs are contraindicated in this population so they should be avoided in the setting of cirrhosis. Beyond that, you’re not left with many options other than opioids that clearly have a lot of potential down sides. This is an area that is right for increased research and investigation to try to find both nonpharmacological and pharmacological options to help patients who are struggling with pain. The goal should be to maximize functionality because patients with NAFLD can improve their disease by increasing physical therapy but that is incredibly difficult when these patients are struggling with a lot of pain or are on medications that limit their ability to remain active.