Opioid use increases risk for serious invasive pneumococcal infections

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. For an embargoed PDF, please contact Angela Collom at acollom@acponline.org or 215-351-2653. The summaries are not intended to substitute for the full articles as a source of information.

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Abstract: http://annals.org/aim/article/doi/10.7326/M17-1907

URLs go live when the embargo lifts

Opioid use is associated with a significantly increased risk for serious invasive pneumococcal infections, such as pneumonia and meningitis. The findings are published in Annals of Internal Medicine.

As opioid use has increased in the U.S., the safety of prescription opioids has come under further scrutiny. In animal studies, use of certain opioids has been associated with increased susceptibility to bacterial infections, including infectious due to Streptococcus pneumoniae, the pathogen that causes invasive pneumococcal disease. Invasive pneumococcal disease includes bacteremia, meningitis, and invasive pneumonia, all of which are associated with high mortality. Although those associations have been well established in animal experiments, it is important to understand the risk of serious infections among humans taking prescription opioid analgesics.

Researchers from The Vanderbilt University Medical Center used data from the Tennessee Medicaid database linked to Medicare and Active Bacterial Core surveillance system databases to test the hypothesis that prescription opioid use is an independent risk factor for invasive pneumococcal disease. They found a significant association between opioid use and the risk of laboratory-confirmed invasive pneumococcal diseases, and that this association was strongest for opioids used at high doses, those classified as high potency and long-acting formulations. The data also showed that opioids previously described as immunosuppressive in prior experimental studies conducted in animals had the strongest association with invasive pneumococcal diseases in humans.

According to the researchers, providers should consider these findings when discussing pain management with their patients.

Note: For an embargoed PDF, please contact Angela Collom. To interview the lead author, Andrew Wiese, PhD, please contact Craig Boerner at craig.boerner@vanderbilt.edu or 615- 322-4747.

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Abstract: http://annals.org/aim/article/doi/10.7326/M18-0251

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Electronic cigarettes have the potential for enormous benefit if they help smokers quit, but they also pose an important threat if they encourage youths to eventually adopt the smoking habit. A new commentary published in Annals of Internal Medicine suggests that users should be cautious about overestimating the health benefits of e-cigarettes.

While e-cigarettes are already being used by millions of Americans, especially youths, little is known about their health risks and benefits. The regulatory standard is that the net benefits of e-cigarettes must exceed their risks, both to the individual user and to the population, but data to inform these decisions has been lacking. A new report from the National Academies of Science, Engineering, and Medicine (NASEM) evaluates the available evidence on e-cigarettes. An accompanying commentary provides advice to physicians on how to counsel patients who ask about e-cigarettes.

According to the NASEM committee, the major finding is that e-cigarettes are less hazardous than combustible cigarettes. Persons who switch completely from smoking combustible tobacco products to vaping e-cigarettes reduce their exposure to cigarette smoke's harmful chemicals and have fewer short-term adverse health outcomes, but the effects of long-term e-cigarette use are not yet known. In contrast, little evidence exists that the use of both e-cigarettes and combustible cigarettes reduces health risks, yet 59 percent of e-cigarette users continue to smoke cigarettes and may overestimate the health benefits of this behavior change.

According to Nancy A. Rigotti, MD, author of the commentary and a tobacco cessation expert at the Tobacco Research and Treatment Center at Massachusetts General Hospital and Harvard Medical School, patients should know that using e-cigarettes is less harmful than continuing to smoke cigarettes, but because e-cigarettes are so new, their long-term safety is unknown. She recommends that smokers use existing FDA-approved stop smoking medications rather than e-cigarettes. If choosing to use e-cigarettes, they should switch completely and avoid smoking combustible cigarettes altogether. Ultimately, the goal with e-cigarettes is for patients to become non-smokers and non-vapers.

Media contacts: For an embargoed PDF, please contact Angela Collom. To interview the lead author, Nancy Rigotti, MD, please contact Noah Brown at nbrown9@partners.org or 617-643-3907.

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Abstract: http://annals.org/aim/article/doi/10.7326/M17-1970

Editorial: http://annals.org/aim/article/doi/10.7326/M17-3420

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Low-strength evidence suggests that cranial electrical stimulation (CES) is safe and may have some benefit for patients with anxiety and depression. Researchers found insufficient evidence to determine if CES had any clinically important effects on fibromyalgia, headache, neuromusculoskeletal pain, degenerative joint pain, depression alone, or insomnia. Findings from a systematic review are published in Annals of Internal Medicine.

CES is among a growing number of noninvasive brain stimulation interventions that change brain function. A CES devise uses strategically placed electrodes to deliver a custom current to the head. While the devises are widely available and consumer interest is increasing, the clinical benefits are unclear.

Researchers for the Veterans Affairs Quality Enhancement Research Initiative reviewed 28 articles from 26 randomized trials to determine the benefits and harms of CES for adult patients with chronic painful conditions, depression, anxiety, and insomnia. The researchers found limited evidence to support the use of CES, as published randomized controlled trials were small, had questionable validity and power, and were limited by lack of assessment of adequate blinding. Many of the studies did not provide sufficient detail about patients' existing treatments or report small effects and reported results were often inconsistent. Limited evidence suggested that CES could help patients with anxiety and depression, but better studies are needed to prove this benefit.

Media contacts: For an embargoed PDF, please contact Angela Collom. The lead author, Paul Shekelle, MD, please contact the Veterans Affairs press office at VHAGLAPublicAffairs@va.gov or 310-268-3340.

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Pharmaceutical Benefit Managers, Brand-Name Drug Prices, and Patient Cost Sharing
Ge Bai, PhD, CPA; Aditi P. Sen, PhD; and Gerard F. Anderson, PhD
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2506

A Cautionary Tale of Warning Messages on Food Products: The Case of Sugar-Sweetened Beverages
Richard Kahn, PhD
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2659

Why Internists Might Want Single-Payer Health Care
Paul Sorum, MD, PhD
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2678

The Care Continuum for Hospitalized Medicare Beneficiaries Near Death
Daniel E. Lage, MD, MSc; Daryl J. Caudry, SM; D. Clay Ackerly, MD, MSc; Nancy L. Keating, MD, MPH; David C. Grabowski, PhD
Brief Research Report
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2651

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