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Patterns of inpatient opioid use linked to long-term use

By Nicole Mackee
Patterns of inpatient opioid use may put patients at risk of long-term use after discharge, say US researchers.

In a retrospective cohort study published in the Annals of Internal Medicine, researchers evaluated 191,249 admissions (among 148,068 patients) over a five-year period.

Opioids were administered in 48% of admissions, which doubled patients’ risk of opioid use at 90 days after discharge (5.9% vs 3.0% with no inpatient opioid use). Opioid use at 90 days was higher in inpatients receiving opioids less than 12 hours before discharge (7.5%) than in patients with at least 24 opioid-free hours before discharge (3.9%), the researchers found.

Professor Stephan Schug, Professor and Chair of Anaesthesiology at the University of Western Australia, said the findings were likely to apply in Australia, which had one of the highest rates of opioid use in the world.

‘It is not as bad as the US, but there are very similar patterns observable in Australia with regards to over prescribing of opioids in chronic pain, misuse and abuse of prescribed opioids, and even opioid-induced mortality,’ Professor Schug said. He pointed to Australian research (BMJ Open 2019; 9: e023990) that found that inpatient opioid initiation for postsurgical pain led to chronic opioid use for a small percentage of patients.

The concept of ‘opioid stewardship’ was gaining traction in Australia and would help to encourage appropriate use and ‘deprescribing’, Professor Schug said. ‘Patients get information on how to come off the opioid and GPs are getting letters from the hospital pain service about the tapering regimen for the individual patient,’ he said.

Professor Schug said opioid pack sizes were also an issue, and he supports a proposal by the TGA that manufacturers provide smaller packs of six to eight tablets for discharge. The smallest packs currently available contain 20 tablets.

Professor Schug said it was important to remember that longer-term opioid use may sometimes be appropriate.

‘One has to be always careful with these data because [in this study] they cannot differentiate the cancer-pain patient or the patient with severe trauma,’ Professor Schug said. ‘They may be discharged on an opioid and may still be using it some months later, and that may be totally appropriate.’

In the US and Australia there was also a push for earlier discharge, particularly after surgeries such as joint replacement, and these patients often required a limited duration of opioid therapy after discharge.

‘There is some tension between, on the one hand, not using opioids; but on the other hand, getting patients out of hospital early and giving them the chance to rehabilitate properly.’
Ann Intern Med 2019; doi: 10.7326/M18-2864.