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Nearly one in five patients with cirrhosis were prescribed opioids during outpatient visits, more often than not by a primary care physician (PCP), according to a national analysis of over 10 million ambulatory visits.

From 2006 to 2016, 17% of all outpatient visits for patients with cirrhosis resulted in an opioid prescription, usually a refill, reported Anna Lee, MD, of the University of California Los Angeles, during a presentation at the virtual American Association for the Study of Liver Diseases (AASLD) meeting.

Among the 1.7 million visits involving an opioid prescription, 68% were with PCPs while 29% were with a gastroenterologist (GI). Of these, 41% involved patients without a documented pain diagnosis, a "concerning" finding that requires further study, said Lee.

Due to the inherent liver dysfunction, pain control "is actually pretty difficult in cirrhosis patients," said Lee. As many have musculoskeletal pain, she suggested that physical therapy could be beneficial.

"Neuropathic pain is also pretty common, diabetic neuropathy was something that came up frequently, suggesting neuropathic agents could be another option," she said.

"I'm grateful that you performed this study, because I think it is really important," Lauren Feld, MD, of the University of Washington in Seattle, told Lee during an AASLD press conference.

"I have seen a lot of both patients and providers under the impression that Tylenol is contraindicated in liver disease, whereas in reality our guidelines recommend that it should be a first-line therapy in cirrhosis, if given in the appropriate amounts," said Feld. "I think that is a very common misconception."

"This is an eye-opening study and very important to help understand the use and possible misuse of opioids in cirrhotic patients," David E. Bernstein, MD, of Northwell Health in Manhasset, New York, told MedPage Today. "The finding that nearly 20% of cirrhotics are prescribed opioids during outpatient visits is quite concerning, as opioids are associated with an increased risk of complications in portal hypertensive patients and cirrhotics are at high risk of developing an addiction to prescribed opioids."

Bernstein, who was not involved in the study, called the finding a wake-up call to educate PCPs and GIs both on the risks of opioid use and misuse in patients with cirrhosis, but also to highlight alternatives to opioids to adequately address pain in this population.

For their study, Lee's group examined data on 10.1 million ambulatory visits of cirrhosis patients from the National Medical Care Survey. Diagnoses were validated by use of ICD-9 or ICD-10 codes, with weighted data calculations providing national estimates.

Overall, the patients were more likely to visit gastroenterologists (53%) than a PCP (41%). Two-thirds of the patients were white, a little more than half were men, 61% were ages 40 to 64, and a third were 65 or older.

Among visits resulting in an opioid prescription, 91% (1.6 million) were renewals. Of those associated with a pain diagnosis, 34% were musculoskeletal in nature, 28% gastrointestinal, and 25% endocrinological. The most commonly prescribed opioids included oxycodone (35%), hydrocodone (25%), and tramadol (19%).

The analysis had several limitations, the researchers acknowledged, including the potential for ICD billing code errors for diagnoses and reporting bias.

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