Skip to main content Accessibility help
×
Home

The impact of opioid medications on subsequent fractures in discharged emergency department patients with peripheral vertigo

  • Keerat Grewal (a1), Peter C. Austin (a2) (a3) (a4), Moira K. Kapral (a5) (a3) (a4), Hong Lu (a4) and Clare L. Atzema (a1) (a2) (a4)...

Abstract

Background

Vertigo is common in the emergency department (ED). Most aetiologies are peripheral and do not require hospitalization, but many patients still fear falling. Some patients may be taking opioid analgesic medications (for other reasons); the risk of falls leading to fractures among patients with vertigo could be potentiated by the simultaneous use of opioids.

Objectives

To examine the risk of fractures in discharged ED patients with peripheral vertigo who were being prescribed opioids during the same time period.

Methods

Linked administrative databases from Ontario were used to compare discharged ED patients aged ≥65 with peripheral vertigo to patients with urinary tract infection (UTI) from 2006 to 2011. We used Cox regression analysis with an interaction term to estimate the modifying effect of an opioid prescription on the hazard of fracture within 90 days.

Results

There were 13,012 patients with a peripheral vertigo syndrome and 76,885 with a UTI. Thirteen percent of the vertigo cohort and 25% of the UTI cohort had access to a filled opioid prescription. Compared to vertigo patients who did not fill an opioid prescription, the adjusted hazard of fracture among vertigo patients who did fill a prescription was 3.59 (95% CI 1.97–6.13). Among UTI patients who filled an opioid prescription the hazard ratio was 1.68 (95% CI 1.43–1.97) compared to UTI patients who did not.

Conclusions

Patients discharged from the ED with peripheral vertigo who were also being prescribed opioids had a higher hazard of subsequent fracture compared to those who were not, and the effect was much greater than among UTI patients. These results suggest that in the acutely vertiginous older patient, opioid analgesic medications should be modified, where possible.

Contexte

Les vertiges sont une cause fréquente de consultation au service des urgences (SU). La plupart sont d’origine périphérique et ne nécessitent pas d’hospitalisation, mais bon nombre de patients craignent toujours de faire des chutes. Certains malades peuvent prendre des analgésiques opioïdes (pour d’autres raisons), et le risque de chute causant des fractures chez les patients qui souffrent de vertiges pourrait être aggravé par la prise concomitante d’opioïdes.

Objectifs

L’étude visait à examiner le risque de fracture chez les patients ayant obtenu leur congé du SU mais éprouvant des vertiges d’origine périphérique, à qui l’on avait prescrit des opioïdes durant la même période.

Méthode

Nous avons établi des liens entre des bases de données administratives en Ontario afin de comparer des patients âgés de 65 ans et plus, atteints de vertiges d’origine périphérique mais ayant obtenu leur congé du SU, avec des patients souffrant d’une infection urinaire (IU), pour la période de 2006 à 2011. Une analyse de régression de Cox avec paramètre d’interaction a permis d’estimer l’effet modificateur des prescriptions d’opioïdes sur le risque de fracture au cours des 90 jours suivants.

Résultats

L’étude comptait 13 012 patients éprouvant des vertiges d’origine périphérique et 76 885 patients souffrant d’une IU. Treize pour cent de ceux qui se trouvaient dans la cohorte des malaises vertigineux et 25 % de ceux qui se trouvaient dans la cohorte des IU ont fait exécuter une ordonnance d’opioïdes. Le risque rajusté de fracture chez les patients qui avaient des vertiges et qui avaient fait exécuter une ordonnance d’opioïdes comparativement à ceux qui ne l’avaient pas fait était de 3,59 (IC à 95 % : 1,97–6,13). Quant aux patients souffrant d’une IU, le rapport des risques instantanés était de 1,68 (IC à 95 % : 1,43–1,97) entre ceux qui avaient fait exécuter une ordonnance d’opioïdes et ceux qui ne l’avaient pas fait.

Conclusions

Le risque de fracture consécutif à la prise d’opioïdes était plus élevé chez les patients éprouvant des vertiges d’origine périphérique mais ayant obtenu leur congé du SU, à qui l’on avait prescrit des opioïdes que chez ceux à qui l’on n’en avait pas prescrit, et l’effet était beaucoup plus grand que chez les patients souffrant d’une IU. Les résultats donnent à penser qu’il faudrait modifier, dans la mesure du possible, les opioïdes chez les patients âgés qui éprouvent des vertiges importants.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      The impact of opioid medications on subsequent fractures in discharged emergency department patients with peripheral vertigo
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      The impact of opioid medications on subsequent fractures in discharged emergency department patients with peripheral vertigo
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      The impact of opioid medications on subsequent fractures in discharged emergency department patients with peripheral vertigo
      Available formats
      ×

Copyright

Corresponding author

Correspondence to: Dr. Keerat Grewal, Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Room G157, Toronto ON M4N 3M5; Email: keerat.grewal@mail.utoronto.ca

References

Hide All
1. Kerber, KA, Meurer, WJ, West, BT, Fendrick, AM. Dizziness presentations in U.S. emergency departments, 1995–2004. Acad Emerg Med 2008;15(8):744-750.
2. Walker, HK, Hall, WD, Jurst, JW. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston: Butterworth; 1990.
3. Cappello, M, di Blasi, U, di Piazza, L, et al. Dizziness and vertigo in a department of emergency medicine. Eur J Emerg Med 1995;2(4):201-211.
4. Karatas, M. Central vertigo and dizziness: epidemiology, differential diagnosis, and common causes. Neurologist 2008;14(6):355-364.
5. Kerber, KA, Baloh, RW. The evaluation of a patient with dizziness. Neurol Clin Pract 2011;1(1):24-33.
6. Holmes, S, Padgham, ND. A review of the burden of vertigo. J Clin Nurs 2011;20(19–20):2690-2701.
7. Atzema, CL, Grewal, K, Lu, H, et al. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol 2016;79(1):32-41.
8. International Opioids Control Board. Opioid Consumption Motion Chart. Madison: Board of Regents of the University of Wisconsin System; 2012. Available at: https://ppsg.medicine.wisc.edu/chart (accessed May 18, 2017).
9. Gomes, T, Mamdani, MM, Paterson, JM, Dhalla, IA, Juurlink, DN. Trends in high-dose opioid prescribing in Canada. Can Fam Physician 2014;60(9):826-832.
10. Rolita, L, Spegman, A, Tang, X, Cronstein, BN. Greater number of opioid analgesic prescriptions for osteoarthritis is associated with falls and fractures in elderly adults. J Am Geriatr Soc 2013;61(3):335-340.
11. Grewal, K, Austin, PC, Kapral, MK, Lu, H, Atzema, CL. Missed stroked using computed tomography imaging in patients with vertigo: a population-based cohort study. Stroke 2015;46(1):108-113.
12. Ontario Ministry of Health and Long-Term Care. Ontario Health Insurance Plan (OHIP). Available at: http://www.health.gov.on.ca/en/public/programs/ohip/(accessed May 18, 2017).
13. Iron, K, Zagorski, BM, Sykora, K, Manuel, DG. Living and Dying in Ontario: An Opportunity for Improved Health Information. Toronto: Institute for Clinical Evaluative Sciences; 2008. Available at: https://www.healthsystemsevidence.org/articles/26617-living-and-dying-in-ontario-an-opportunity-for-improved-health-information-ontario?t=Livingandd&ampsource=search&amplang=pt (accessed May 18, 2017).
14. Austin, PC, Daly, PA, Tu, JV. A multicenter study of the coding accuracy of hospital discharge administrative data for patients admitted to cardiac care units in Ontario. Am Heart J 2002;144(2):290-296.
15. Gershon, AS, Wang, C, Guan, J, et al. Identifying individuals with physician diagnosed COPD in health administrative databases. COPD 2009;6(5):388-394.
16. Hux, JE, Ivis, F, Flintoft, V, Bica, A. Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm. Diabetes Care 2002;25(3):512-516.
17. Schultz, SE, Rothwell, DM, Chen, Z, Tu, K. Identifying cases of congestive heart failure from administrative data: a validation study using primary care patient records. Chronic Dis Inj Can 2013;33(3):160-166.
18. Tu, K, Campbell, NR, Chen, ZL, Cauch-Dudek, KJ, McAlister, FA. Accuracy of administrative databases in identifying patients with hypertension. Open Med 2007;1(1):e18-e26.
19. Charlson, ME, Pompei, P, Ales, KL, MacKenzie, CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373-383.
20. Johns Hopkins University. The Johns Hopkins ACG® System: Decades of Impact on Population Health Research and Practice. Baltimore: Johns Hopkins University; 2017. Available at: http://www.acg.jhsph.edu (accessed May 19, 2017).
21. Beveridge, R, Clarke, B, Janes, L, et al. Implementation Guidelines for the Canadian Emergency Department Triage & Acuity Scale (CTAS). Ottawa: Canadian Association of Emergency Physicians; 2015. Available at: http://caep.ca/sites/caep.ca/files/caep/files/ctased16.pdf (accessed May 19, 2017).
22. Fernandez, L, Breinbauer, HA, Delano, PH. Vertigo and dizziness in the elderly. Front Neurol 2015;6:144.
23. Agrawal, Y, Carey, JP, Della Santina, CC, Schubert, MC, Minor, LB. Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001–2004. Arch Intern Med 2009;169(10):938-944.
24. Liao, WL, Chang, TP, Chen, HJ, Kao, CH. Benign paroxysmal positional vertigo is associated with an increased risk of fracture: a population-based cohort study. J Orthop Sports Phys Therapy 2015;45(5):406-412.
25. Mueller, M, Schuster, E, Strobl, R, Grill, E. Identification of aspects of functioning, disability and health relevant to patients experiencing vertigo: a qualitative study using the international classification of functioning, disability and health. Health Qual Life Outcomes 2012;10:75.

Keywords

Related content

Powered by UNSILO
Type Description Title
WORD
Supplementary materials

Grewal supplementary material
Table E1

 Word (59 KB)
59 KB

The impact of opioid medications on subsequent fractures in discharged emergency department patients with peripheral vertigo

  • Keerat Grewal (a1), Peter C. Austin (a2) (a3) (a4), Moira K. Kapral (a5) (a3) (a4), Hong Lu (a4) and Clare L. Atzema (a1) (a2) (a4)...

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.