Predictors of In-hospital Postoperative Opioid Overdose After Major Elective Operations

Abstract

Objective: To describe national trends and outcomes of in-hospital postoperative opioid overdose (OD) and identify predictors of postoperative OD. Summary Background Data: In 2000 the Joint Commission recommended making pain the 5th vital sign, increasing the focus on postoperative pain control. However, the benefits of pain management must be weighed against the potentially lethal risk of opioid OD. Methods: This is a retrospective multi-institutional cohort study of patients undergoing one of six major elective inpatient operation from 2002 to 2011 using the Nationwide Inpatient Sample, an approximately 20% representative sample of all United States hospital admissions. Patients with postoperative OD were identified using ICD-9 codes for poisoning from opioids or adverse effects from opioids. Multivariate logistic regression was used to identify independent predictors. Results: Among 11,317,958 patients, 9,458 (0.1%) had a postoperative OD; this frequency doubled over the study period from 0.6 to 1.1 overdoses per 1,000 cases. Patients with postoperative OD died more frequently during their hospitalization (1.7% vs. 0.4%, p-value < 0.001). Substance abuse history was the strongest predictor of OD (OR=14.8; 95% CI: 12.7–17.2). Gender, age, income, geographic location, operation type, and certain comorbid diseases also predicted OD (p<0.05). Hospital variables including teaching status, size, and urban/rural location did not predict postoperative OD. Conclusions: Postoperative OD is a rare, but potentially lethal complication, with increasing incidence. Postoperative monitoring and treatment safety interventions should be thoughtfully employed to target high risk patients and avoid this potentially fatal complication.

Risk factors for opioid overdose among hospitalized patients

“…Our study indicates that advanced age (≥65 years old), being in an ICU, renal impairment and concomitant use of CNS depressants increase the likelihood of having an opioid overdose among hospitalized patients. The results of this study are similar to what was found in previous large study of more than 11 million patients undergoing a major selective operation: advanced age (≥60 years old) and renal disease were predictors, with renal disease being the strongest comorbid predictor (OR 2.89, 95% CI 2.45‐3.41) after history of substance use disorders (OR 14.81, 95% CI 12.74‐17.21) . We excluded patients with a documented history of substance use disorder from our study as a potential confounding factor to examine dose‐related effect as this patient population may not reflect the general population and likely have significant tolerance.…”

“…According to a recent study of more than 11 million patients undergoing a major inpatient operation between 2002 and 2011, the in‐hospital mortality rate was more than 4 times higher in the group of patients who had a postoperative opioid overdose compared to those who did not (1.7% vs 0.4%, P < .001). Hospital length of stay and total healthcare cost were also significantly greater for patients who had a postoperative overdose than those who did not (6.7 vs 3.9 days; $83 655 vs $46 255; P < .001) …”

“…Hospital length of stay and total healthcare cost were also significantly greater for patients who had a postoperative overdose than those who did not (6.7 vs 3.9 days; $83 655 vs $46 255; P < .001). 13 The 2017 draft on pain management for hospital accreditation programs recently released by the Joint Commission emphasizes the safe use of opioid medication. 14 Clinicians are required to assess the risk of treatment with opioids and to monitor patients who are considered high risk for adverse outcomes from such treatment.…”

“…A more recent, larger study using the Nationwide Inpatient Sample from 2002 to 2011 concluded that a history of substance abuse history was the strongest predictor of opioid overdose (OR = 14.5, CI 12.7-17.2), followed by gender, age and certain comorbid diseases. 13 However, this study only focused on inpatient pain management of patients undergoing major elective operations. Uncertainties of inpatient predictive factors remained due to the lack of a more recent and relevant update.…”

The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery

“…Obtaining sufficient postoperative pain control can also allow for earlier mobilization and has the ability to shorten a patient's LOS thereby decreasing hospital costs [3,4]. The current standard therapy for postoperative pain management consists of opioid medications, however, with the current epidemic of overdoses and abuse, physicians must consider the potential risks when formulating a postoperative pain regimen [5,6]. The importance of postoperative pain control and potential detrimental side-effects of opioid medications lends to the importance of finding alternative analgesic interventions with improved adverse-effect profiles [7].…”