Clinical Topics

Prescribed Opioids Increase Risk of Pneumonia in Veterans

by Brenda Mooney

February 24, 2019

NEW HAVEN, CT–A study looking at whether taking prescribed opioids increased pneumonia risk in veterans with HIV vs. those without came to a disturbing conclusion: The likelihood is increased in both.

The study, published in JAMA Internal Medicine, bolstered the argument that prescription opioid painkillers have a negative impact on the immune system, with an even greater effect on HIV patients.1

The Yale University-led research, which including participation from VAMCs in West Haven, CT, Washington, Salt Lake City, UT, and Houston, also emphasized the responsibility of prescribers to take steps to minimize pneumonia risk.

“This study adds to growing evidence of potential medical harms associated with prescribed opioids,” the authors cautioned. “Health care professionals should be aware of this additional CAP risk when they prescribe opioids, and future studies should investigate the effects of opioids prescribed for longer durations and on other immune-related outcomes.”

Background information in the article pointed out that opioids such as codeine, fentanyl, and morphine suppress the immune system and curb the ability to fight bacterial infections, such as pneumonia.

Data was from patients enrolled in the Veterans Aging Cohort Study, with the study team focusing on those who were treated at a VA between 2000 and 2012 – with and without HIV diagnoses. Patients hospitalized for pneumonia were matched with similar patients who did not have pneumonia.

The 25,392 mostly male participants with a mean age of 55, current medium doses of opioids with unknown or no immunosuppressive properties (adjusted odds ratio [AOR], 1.35; 95% CI, 1.13-1.62) and immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and current high doses of opioids with unknown or no immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and immunosuppressive properties (AOR, 3.18; 95% CI, 2.44-4.14) were associated with the greatest CAP risk. That was in comparison with no prescribed opioids or any past prescribed opioid with no immunosuppressive (AOR, 1.24; 95% CI, 1.09-1.40) and immunosuppressive properties (AOR, 1.42; 95% CI, 1.21-1.67), especially with current receipt of immunosuppressive opioids.

Immunosuppressive Opiods

After analysis, the study found that CAP risk was consistently greater among people living with HIV with current prescribed opioids, especially when prescribed immunosuppressive opioids (eg, AORs for current immunosuppressive opioids with medium dose, 1.76 [95% CI, 1.20-2.57] vs 2.33 [95% CI, 1.60-3.40]).

In fact, the researchers found that patients with HIV tended to be more likely to develop pneumonia even at low doses of opioids and especially with immunosuppressive opioids.

“We saw that prescription opioids were independently associated with pneumonia requiring hospitalization,” explained E. Jennifer Edelman, MD, the corresponding author and an associate professor at Yale School of Medicine.

Cough, respiration, and mucus secretion all can be effected by prescription opioids, Edelman noted, adding that the study “lends credence to the hypothesis that opioids have effects on the immune system that are clinically relevant.”

“Understanding whether mitigating the risk of prescribed opioids for CAP is possible by using a lower dose and non-immunosuppressive opioids awaits further study,” study authors wrote. “For now, in those settings when prescribed opioids are warranted, care should be implemented to address other risk factors (eg, smoking cessation and vaccination) known to modify CAP risk.”

The study also suggested that providers could consider prescribing lower doses of opioids or opioids that do not suppress the immune system.

The issue is heightened for patients with HIV, the researchers emphasized. Those patients are more commonly prescribed opioids than others, even though they have increased risk for infectious complications in general and for CAP in particular.

“Notably, CAP is a major contributor to morbidity and mortality even in the current HIV treatment era and especially as patients age,” the authors wrote.

The study team concluded, “We observed a differential association of prescribed opioids with CAP risk by HIV status based on opioid dose and immunosuppressive properties as the magnitude of the association between these opioid characteristics, and CAP risk was higher for [people living with HIV] compared with uninfected patients.”

1. Edelman EJ, Gordon KS, Crothers K, Akgün K, Bryant KJ, Becker WC, Gaither JR, Gibert CL, Gordon AJ, Marshall BDL, Rodriguez-Barradas MC, Samet JH, Justice AC, Tate JP, Fiellin DA. Association of Prescribed Opioids With Increased Risk of Community-Acquired Pneumonia Among Patients With and Without HIV. JAMA Intern Med. 2019 Jan 7. doi: 10.1001/jamainternmed.2018.6101. [Epub ahead of print] PubMed PMID: 30615036.

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