The Opioid Epidemic and AF

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The daily news continues to bring headlines of widespread opioid addiction and abuse and its devastating impact on individuals and communities. Less often heard are reports on the negative health effects of opioid analgesics used as prescribed. One interesting study presented at the 2018 AHA Scientific Sessions in Chicago this week uncovered an association between an increased risk of atrial fibrillation (AF) and opioid use.

Kudos to the researchers who thought to investigate this association-a relationship that is not readily apparent. Jonathan D. Stock, MD, and colleagues at Yale-New Haven Hospital, reported on their analysis of 857 283 young veterans (mean age 38 years, 86% men, 59% white) that showed a stronger than expected association between use of prescribed opioids (even short-term) and development of AF.¹ Although AF is traditionally considered a disease of the aging population, it was surprising to find that, after multivariate adjustment for comorbidities, demographics, and mental health conditions, individuals with an opioid prescription were 34% were more likely (CI 1.23-1.45, p<.001) than those without a prescription to develop AF. The overall incidence of AF was 0.35% (3033 of the 857 233 participants). This independent association held true even with short-term opioid prescriptions and at therapeutic (not supraphysiologic) doses. Not surprisingly, veterans tended to have a higher rate of opioid prescriptions than the general population.¹

There was no association noted between opioid prescription duration and prevalence of AF nor were there significant differences based on race. More men than women in the study had AF, reflecting the general population, but even after correction for sex, the association held.¹

The authors speculated that the increased risk of AF may be a result of sleep-disordered breathing. These findings build on a recent study that showed an increase in all-cause mortality with a hazard ratio for cardiovascular death of 1.65 in those with chronic noncancer pain taking long-acting opioid medication.²

This large retrospective study has the typical limitations associated with observational analyses that show association (not necessarily causation) and so definitive conclusions require further research. However, until now the implications for their practice of the opioid epidemic may not have been top of mind for many cardiologists. This study is among an increasing number that highlight the cardiovascular dangers, including mortality, of opioid use/abuse-and in this case the development of arrhythmias linked to the analgesics used as prescribed.

Perhaps the study’s most important take home is this: we may want to start screening those with opioid prescriptions more carefully for new onset atrial fibrillation.

References:

1. Stock JD, Chui P, Rosman L, Malm BJ, et al. Assocation of opioid use with atrial fibrillation in a post-9/11 veteran population. Circulation. 2018;138:A12773

2. Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315:2415–2423. doi:10.1001/jama.2016.7789.