Screening for Osteoporosis Risk in Male Patients on Long-Term Opioid Therapy

Screening for Osteoporosis Risk in Male Patients on Long-Term Opioid Therapy

Background: The Bone Health and Osteoporosis guidelines recommend screening for osteoporosis in male patients starting at age 70 using dual energy X-ray absorptiometry (DXA). In the absence of a DXA scan, recently obtained CT or MRI imaging obtained for other purposes can be reviewed for the presence of clinically significant findings, such as previous vertebral fracture or osteopenia, which may indicate the need for further evaluation of osteoporosis. While the prevalence of osteoporosis is less in males, this population has been associated with higher risk of mortality following a fracture. The use of long-term opioid therapy increases osteoporosis risk through pituitary gland suppression leading to decreased testosterone and secondary hypogonadism development, which is a major osteoporosis risk factor.

Purpose/Objectives: To evaluate the compliance of completing DXA scans in male patients age ≥ 70 years old and who are managed on chronic long-acting opioid therapy. 

Method: A retrospective chart review was conducted as a quality improvement project of patients at a single Veteran Affairs (VA) healthcare facility who were male and age ≥ 70 years that were prescribed chronic therapy with a long-acting opioid analgesic between July 20^th, 2021 and July 20^th, 2022, for a period ≥ 90 days. Information reviewed included patient demographics, long-acting opioid prescribed, if concomitant immediate release (IR) opioid therapy was prescribed, ordering discipline, total morphine milligram equivalent (MME), length of current long-acting opioid therapy, and total length of opioid therapy.  Charts were reviewed for history of DXA scan completion and the ordering provider, additional osteoporosis risk factors and if an osteoporosis diagnosis was present in the problem list. Additionally, charts were reviewed for previous CT or MRI imaging that indicated the presence of vertebral fracture.  Patients were excluded if they were no longer receiving a long-acting opioid or deceased.

Results: Initial query identified 107 charts. 90 met inclusion criteria for review. Most patients (81.1%) were between 70-79 years old. Most common long-acting opioid was buprenorphine (31.1%) then methadone (22.2%) and morphine (17.8%).  IR opioids were prescribed to 24 patients. Primary care issued most prescriptions (92.2%). Only 26.7% patients had a previous DXA, 54.2% were ordered by Endocrinology.  64 of 90 patients had a previous CT or MRI, with 14 having evidence of vertebral fracture and 19 with osteopenia, however, only 25% also had a DXA. Only 1 of 90 patients had a listed osteoporosis diagnosis at the time of review.

Conclusions: This retrospective review indicates osteoporosis screening is underperformed at our facility for male patients who meet age-based criteria for screening, and who are receiving chronic long-acting opioids, which can further increase osteoporosis risk. This could indicate a potential under diagnosis of osteoporosis in this population. This is perhaps, underscored by only 1 patient having a listed osteoporosis diagnosis in the active problem list at the time of review. A rate which is much lower than the national average for geriatric males. The low incidence of DXA completion in patients with CT or MRI could indicate a need for additional education. As the majority prescribing discipline was primary care, this could indicate potential opportunities for increased specialty care involvement.

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