Association Between Opioids Prescribed to Medical Inpatients With Pain and Long-Term Opioid Use

Kaitlin E. Keenan, MD; Michael B. Rothberg, MD, MPH; Shoshana J. Herzig, MD, MPH; Simon Lam, PharmD, BCPS; Vicente Velez, MD; Kathryn A. Martinez, PhD, MPH

Disclosures

South Med J. 2021;114(10):623-629. 

In This Article

Abstract and Introduction

Abstract

Objectives: Opioid receipt during medical hospitalizations may be associated with subsequent long-term use. Studies, however, have not accounted for pain, which may explain chronic use. The objective of this study was to identify the association between opioid exposure during a medical hospitalization and use 6 to 12 months later.

Methods: This was an observational cohort study using electronic health record data from 10 hospitals in the Cleveland Clinic Health System in 2016. Eligible patients were opioid-naïve adults with pain age 18 years and older, admitted to a medical service. Outcomes were opioid receipt during hospitalization and on discharge, and long-term opioid use, defined as ≥2 prescriptions for at least 30 pills 6 to 12 months posthospitalization. We estimated the odds of long-term opioid use by opioid exposure during the hospitalization. Models controlled for patient demographic and clinical characteristics, including patient-reported pain.

Results: Among the 2971 patients in the sample, 64% received opioids during their hospitalization and 28% were discharged with opioids. Overall, 3% of patients had long-term use. Higher pain score was associated with greater odds of long-term use (adjusted odds ratio [aOR] per point increase 1.11; 95% confidence interval [CI] 1.03–1.19). No patient factors were associated with long-term use. Receipt of an opioid during a hospitalization only was not associated with long-term use (aOR 1.44, 95% CI 0.81–2.57), but receipt at discharge was (aOR 1.96, 95% CI 1.08–3.56).

Conclusions: Although opioid receipt at discharge was associated with long-term use, the number of patients this applied to was small. Pain severity was an important predictor of long-term use and should be accounted for in future studies.

Introduction

Overuse of opioids resulted in 67,000 opioid-related deaths in 2018.[1–3] Healthcare settings are key opioid exposure points. In 2012, 289 million opioid prescriptions were supplied to patients via physicians. Much investigation regarding opioid prescribing has centered on opioids following surgery,[4–8] in the emergency department,[9–11] and in primary care.[12] These studies have identified variability in physician prescribing practices,[13] as well as factors associated with increased risk of long-term opioid use by patients.[6,7,10,14]

Less is known about opioid prescribing for hospitalized patients on the Medicine service. Long-term opioid therapy for noncancer pain has increased substantially in the last 15 years.[15] Medical inpatients often have chronic pain or complex healthcare needs[16] that predispose them to long-term opioid therapy.[17] A 2013 study of medical inpatients in 286 US hospitals found that 51% received opioids during their hospitalization.[18] This study was unable to account for whether patients were using opioids before their hospitalization, how much pain they experienced, the reason opioids were prescribed, and whether they were prescribed on discharge, leaving several important questions unanswered.

How opioid exposure affects long-term use is a critical question. Some studies have found that, for opioid-naïve patients, opioid exposure during a medical hospitalization is associated with long-term use.[19–22] These did not account for presence or severity of patient-reported pain, however, which are likely important confounders between opioid receipt in the hospital and continued use long term. In addition, these studies either looked at opioid receipt during the hospitalization[20] or at discharge.[19,21,22] We therefore do not know whether there are differences in the risk of long-term use based on the timing and type of opioid exposure related to the hospitalization. Lastly, unlike surgical patients, who presumably receive opioids for acute postoperative pain, the most common reasons that medical patients receive opioids has not been investigated. Our understanding of the association between opioid exposure during a medical hospitalization and long-term use is therefore inadequate.

The objective of our study was to describe the characteristics of opioid-naïve patients receiving opioids during an acute medical hospitalization. We investigated whether opioid receipt during the hospitalization or at discharge was associated with long-term use. To understand why patients were given opioids, we also assessed opioid-related documentation in patient charts.

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