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Reported NSAID allergies may increase risk for opioid use disorder

Published: September 8, 2020

The opioid epidemic remains a pressing public health issue. It is imperative to identify patients at highest risk for opioid use disorder and to address challenges in reducing opioid use.  Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for first-line treatment of pain, but a reported history of NSAID-induced adverse reactions can preclude therapeutic use of this entire medication class. The vast majority of reported NSAID reactions represent side effects or intolerances (e.g., gastrointestinal upset, bleeding) and only a minority (~20%) reflect true allergic hypersensitivity (e.g., urticaria and/or angioedema, anaphylaxis). However, “allergy” over-reporting and lack of reaction clarification may lead to unnecessary avoidance of NSAIDs and predispose patients to the use of stronger and potentially addictive pain medications with negative downstream effects on patient outcomes. The relationships between reported NSAID “allergies,” opioid prescribing, and opioid use disorder are unknown.   

In a research article recently published in The Journal of Allergy and Clinical Immunology (JACI), Li and colleagues investigated whether reported NSAID allergies were associated with increased risk of developing opioid use disorder in a cohort of over 47,000 adults with chronic back pain. The study took place in Boston, Massachusetts between 2013 and 2018. In this study, the authors collected patient demographic, clinical and prescription data and assessed for development of opioid use disorder over a 5-year follow-up period.

Reported NSAID allergies were twice as common in patients with chronic back pain than for the general population. There were consistent positive associations between reported NSAID allergy and development of opioid use disorder, even after adjusting for patient baseline characteristics and comorbidities. Additional risk factors for opioid use disorder included younger age, male sex, Medicaid or Medicare insurance, higher prior healthcare utilization, and comorbid anxiety and depression. Reported NSAID allergy was also associated with higher odds of documented opioid prescriptions.  

This is the first study to examine whether reported NSAID allergy labeling is associated with increased opioid prescriptions and higher risk for opioid use disorder. The results suggest that the label “NSAID-allergic” impacts physician prescribing patterns and the development of opioid use disorder in adult patients with chronic back pain. These findings highlight the importance of allergy evaluation for potential delabeling of patients with reported NSAID allergies, and support the need for additional studies to examine the impact of NSAID allergy labels on clinical outcomes in other patient groups.  

The Journal of Allergy and Clinical Immunology (JACI) is an official scientific journal of the AAAAI, and is the most-cited journal in the field of allergy and clinical immunology.

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