Inpatient Opioid Use May Increase Outpatient Opioid Prescription Use

Author(s):

Reducing use of opiates near the end of hospital stay, especially 24 hours prior to discharge, may reduce outpatient prescription of opioids.

Jason Kennedy, MS, research project manager, University of Pittsburgh School of Medicine Department of Critical Care Medicine

Jason Kennedy, MS, Photo: Jim Rieker

New research presented at the 2018 American Thoracic Society International Conference concluded that in a large health system, opioids were administered to one-half of previously-naïve patients and were associated with a 2-fold increase in subsequent outpatient use within 90 days of discharge.

The study, conducted by University of Pittsburgh School of Medicine scientists, is the first large-scale evaluation focusing on the impact of in-hospital opioid prescribing on post-discharge opioid use.

"Our goal was to describe patterns of inpatient opioid use and investigate specific patterns of inpatient opioid use that may be modifiable targets to reduce subsequent outpatient use," Jason Kennedy, MS, research project manager, University of Pittsburgh School of Medicine’s Department of Critical Care Medicine, told MD Magazine. "Findings indicated that opioid use during care transitions and proximal to discharge may be promising modifiable targets for interventions. Additionally, efforts to curb outpatient use may need integration with amount and timing of inpatient opioid use. That said, our work was conducted in a large health system and further work is needed to generalize findings to other health systems and geographic regions.”

Researchers linked 357,413 electronic health records with outpatient data of non-obstetrical adults hospitalized between 2010—2014 in 12 University of Pittsburgh Medical Center hospitals in southwestern Pennsylvania.

Patients who were opioid-naïve for 12 months prior to hospitalization and had >1 outpatient visit in the 12 months prior and after admission were included in the study.

Researchers found that 192,240 participants (54%) were opioid naïve for 12-months prior to hospitalization, and one-half (n = 93, 193, 48%) received opioids during hospitalizations.

The median time to first opioid use was 24 hours, and initial dose was more frequently administered in the medical ward than ICU or emergency department (39% vs. 10% or 14%, respectively, P <0.01) however, opioids were more common in surgical encounters than medical (64% vs. 42%, P <0.01).

Of the patients receiving opioids in the ICU, 20% received intravenous opioids on transition to the ward.

In the time period 24 hours prior to discharge, 33% patients received an opioid.

After discharge, 6% received opioids within 90 days and were at greater risk among those with inpatient exposure (OR= 2.04, 95% CI: 1.81, 2.31). Those patients receiving hospital opioids were more than twice likely to report outpatient opioid use within 90-days (8.4% vs. 4.1%).

Patients who took an opioid for more than 3/4 of their stay were 32% more likely than those who took an opioid for less than 1/4 of their stay to be prescribed an opioid within 90 days of leaving the hospital.

Those who used an opioid within 12 hours of discharge were twice as likely as those who stopped taking an opioid more than 24 hours prior to discharge to be prescribed another opioid within 90 days of leaving the hospital.

Factors that were independently associated with inpatient opioid use included older age (P <0.01), prior benzodiazepine use (P <0.01) and comorbid behavioral health and pain conditions (P <0.01 for all).

Additional factors that were found independently associated with outpatient use included <12 opioid-free hours prior to discharge (aOR=2.06, 95% CI 1.81, 2.35, P <0.01) and a greater proportion of stay using opioids (aOR= 1.32, 95% CI: 1.17, 1.49, for 76—100% vs. 25% of stay using opioids).

Specific patterns of inpatient use during care transitions and close to discharge may be needed to reduce subsequent outpatient use.

"Further study, ideally with randomized, controlled trials, would be necessary to provide definitive guidance to doctors and other health care providers," Kennedy concluded. "That said, our findings suggest some inpatient interventions that might reduce opioid use in outpatient settings. Reducing use of opiates near the end of a hospital stay, especially in the 24 hours before discharge, may reduce outpatient prescription of opioids. And weaning ICU patients off of intravenous opioids, the most potent way of administering these pain killers, before transitioning them to the medical ward may also help reduce outpatient usage."