A. L. Titan1, L. Graham1, T. Hernandez-Boussard1, E. Dasinger2, J. Richman2, I. Carroll1, M. Morris2, M. T. Hawn1 1Stanford University,Palo Alto, CA, USA 2University Of Alabama at Birmingham,Birmingham, Alabama, USA
Introduction: The “opioid crisis” is man-made national emergency in which over 2 million people in the United States suffer from substance use disorders related to prescription opioids. Evidence suggests inpatient use of opioids is associated with higher rates of adverse events and may impact post discharge outcomes. The aim of this study was to understand variation in preoperative/perioperative opioid exposure and its effect on patients’ perioperative oral morphine equivalent (OME) use, pain scores, and unplanned readmissions.
Methods: National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2007 to 2014 were merged with inpatient analgesia data. Trajectory analysis was used to define three distinct trends in postoperative inpatient OMEs. Bivariate statistics were used to examine characteristics of patients by OME trajectory and multivariate logistic regression was used to examine associations with pain-related readmissions.
Results:Our study sample included 235,239 surgeries. 41.4% of surgeries were categorized as a low inpatient OME trajectory receiving an average of 19.1 OMEs/day (SD 36.0), 53.2% were identified as medium inpatient OME trajectory receiving an average of 39.7 OMEs/day (SD 31.5), and 5.4% were categorized as high inpatient OME use with an average of 116.1 OMEs/day (SD 51.4, Table 1). Opioid use in the prior 6 months was more frequent for the high inpatient OME group compared to the medium or low use groups (72.7% vs. 44.8% and 17.8%, respectively, p<0.01) as was having an active prescription of opioids at the time of surgery (57.2% vs. 29.3% and 21.8%, p<0.01). Patients in the high OME trajectory reported higher inpatient maximum pain scores compared to patients in the lower OME trajectories (9.1, 7.0, 8.0, p<.001) and were more likely to receive acetaminophen (40.2% vs. 27.2% and 18.4%, p<0.01) or NSAIDs (22.2% vs. 16.4% or 8.7%, p<0.01). At discharge 65.7% of patients filled an opioid prescription; high inpatient OME trajectory patients received the highest total OMEs at discharge (825.5 vs. 404.1 and 290.8, p<0.01). Despite more than a two-fold higher OME provided at discharge, patients in high inpatient OME trajectory had a 71% increased odds of pain-related readmission compared to the low OME trajectory (2.4%, 1.4%, 1.4%, p<0.01).
Conclusion:Preoperative and perioperative opioid use are associated with higher overall pain scores and increased risk for pain-related readmissions. Post-operative pain management should account for opioid tolerance. Increased inpatient perioperative use of adjunct non-opioid pain medications for all patients may facilitate decreased requirements of opioids at discharge.
