Defense Date

7-10-2018

Graduation Date

Summer 8-11-2018

Availability

Immediate Access

Submission Type

dissertation

Degree Name

PhD

Department

Nursing

School

School of Nursing

Committee Chair

Melissa Kalarchian

Committee Member

Richard Zoucha

Committee Member

Angela Clark

Keywords

opioid, substance use disorder, surgery, prescribing drugs, postoperative pain, patient characteristics, postoperative, prescribing practice, opioid naive, prolonged opioid use, pain management

Abstract

Background

Research suggests prolonged postoperative opioid use occurs in 4-13% of opioid naïve patients and is related to factors other than surgical pain. However, it is unclear which patient factors and prescribing practices are associated with prolonged use after surgery among opioid naïve patients.

Objectives

To identify factors associated with prolonged postoperative opioid use (refills 90-180 days after surgery) in opioid naïve patients in two domains: specific patient characteristics (demographics, smoking status, comorbidities, etc.) and exposure through postoperative opioid prescriptions (in oral morphine milligram equivalents [OME]).

Methods

An electronic medical record dataset analysis of inpatient and outpatient opioid naïve adult orthopedic surgery patients at the University of Cincinnati Medical Center from January 1, 2012 through December 31, 2017 was conducted. Opioid naïve was defined as no opioid prescription filled in the past twelve months or only a perioperative prescription filled 30 days or less prior to surgery. Patients were excluded if they had a diagnosis of cancer or if they underwent a second surgery within 180 days of the first. A multivariate logistic regression model was used to evaluate the relationship of each domain to opioid refills 90-180 days after surgery.

Results

Of the 7,323 patients met inclusion criteria, 4% continued to refill opioid prescriptions more than 90 days after their surgical procedure. Independent predictors of prolonged postoperative opioid use were alcoholism (O.R. 2.0, C.I. 1.5-2.6), OME > 675 (O.R. 2.3, C.I. 1.5-3.4), female gender (O.R. 1.7, C.I. 1.3-2.1), black race (O.R. 1.6, C.I. 1.2-2.2), Medicaid insurance (O.R. 1.8, C.I. 1.3-2.5), and the following co-morbidities: diabetes (O.R.1.5, C.I. 1.1-2.0), mood disorders (O.R. 1.4, C.I. 1.1-1.9), hypertension (O.R. 1.4, C.I. 1.1-1.9), and chronic kidney disease (O.R. 1.6, C.I. 1.1-2.4).

Conclusions

Both opioid exposure and patient characteristics increase risk for prolonged opioid use following orthopedic surgery. Since the risk of overdose increases with increased OME, patients with high OME prescriptions should also receive a prescription for naloxone. This study sheds light on the need for postoperative prescribing guidelines for clinicians. To decrease the rate of prolonged postoperative opioid use, clinical changes can be investigated and implemented including collaborative perioperative pain management strategies utilizing non-opioid pain control methods; perioperative patient screening; education of patients and clinicians; and close postoperative follow-up, especially for the most vulnerable populations.

Language

English

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