Chronic Opioid Therapy of Hospitalized Patients

Mosher HJ, Kaboli PJ. Chronic Opioid Therapy of Hospitalized Patients. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 25; Denver, CO.

Background: Chronic opioid therapy has grown increasingly prevalent over the last two decades, along with concerns about effectiveness and adverse events. While a robust literature is emerging regarding outpatient management of pain conditions and chronic opioid therapy, there is little to guide management during hospitalization of patients on chronic opioid therapy. Some practitioners are concerned that this paucity of evidence may contribute to ineffective acute management or inappropriate dose escalation at hospital discharge. This study aims to define the prevalence of chronic opioid therapy among patients admitted to hospital, as well as describe the effect of hospitalization on the trajectory of chronic opioid therapy. Methods: This secondary analysis of Veterans Administration inpatient hospitalizations from 2004-2011 included all patients with an index admission, defined as a medical or surgical hospitalization occurring following a minimum 30-day hospitalization-free period. In the case of patients with multiple index admissions during the time period, one index hospitalization was chosen at random. Opioid-use status was determined using outpatient prescription records. Patients were classified into one of three categories: 1) no opioid use, defined as no outpatient opioid prescriptions in 6 months prior to hospitalization; 2) chronic opioid use, defined as 90 or more days supply of opioids prescribed within the 6 months preceding index hospitalization and 3) occasional opioid use, defined as patients who received any opioid prescription during the 6 months prior, but did not meet definition of chronic use. Opioid-use status in the 6 months post-discharge was defined similarly. Frequencies pre- and post-discharge and change in opioid-use status following hospitalization were calculated. Results: A total of 1,341,073 patient hospitalizations were included. In the 6 months prior to admission 847,664 (63.2%) of patients had no opioid use, 232,211 (17.3%) had chronic opioid use, and 261,198 (19.5%) had occasional opioid use. In the 6 months following hospital discharge, 803,969 (60.0%) had no opioid use, 232,040 (17.3%) had chronic opioid use, and 305,064 (22.7%) had occasional opioid use. Although the total percentages were fairly stable, a substantial number of patients transitioned between opioid use categories. Conclusions: In this large sample of hospitalized Veterans, nearly 1 of 5 patients was on chronic opioid therapy at the time of admission, emphasizing the scope of the challenge posed by pain management for inpatients on prior chronic opioid therapy. Hospitalization appears to be a factor in both initiation and cessation of chronic opioid therapy for some patients, suggesting the hospital stay plays an under-recognized role in chronic pain management. Future work will examine opioid use by indication, compare intensity of opioid therapy pre- and post-hospitalization by including morphine equivalents per day, and better characterize patients who transition between opioid-use categories. before and after index hospitalization.