WASHINGTON, DC: Nearly three of four patients who sustain major trauma and receive a new prescription for an opiate pain reliever will discontinue use of the drug by one month after hospital discharge, according to new study results presented at the 2016 Clinical Congress of the American College of Surgeons.
Up to one year after discharge from the hospital, only about 1 percent of trauma patients were reportedly still taking prescription opiates, or opioids, such as hydrocodone, oxycodone, morphine, and fentanyl.
"We were really surprised by how low the numbers were for long-term opiate use," reported senior investigator Andrew Schoenfeld, MD, an orthopaedic surgeon at Brigham and Women's Hospital and assistant professor at Harvard Medical School, Boston. "It appears that traumatic injury is not a main driver for continued opioid use in patients who were not taking opioids prior to their injuries."
Longer term use of opioids can lead to physical dependence, which is characterized by tolerance for the drug and difficulty stopping its use, the National Institute on Drug Abuse reports.1 Misuse of prescription painkillers is a growing public health problem in the United States, with 1.5 million Americans starting to use prescription pain relievers for nonmedical reasons in 2013, according to that year's National Survey on Drug Use and Health.2"Our findings in patients who sustain traumatic injury contradict the popular narrative about the role that appropriate use of opioids may play in the rate of opioid abuse in this country," Dr. Schoenfeld said.
The investigators did, however, identify several risk factors for prolonged opiate use after trauma: age, marital and socioeconomic status, and length of hospital stay.
This new study is one of the largest investigations of prescription opiate use among patients who sustained trauma and may have the longest continued follow-up?one year after hospital discharge, Dr. Schoenfeld stated.Their research was conducted using the 2007 to 2013 database of TRICARE, the Department of Defense health care system that insures active-duty military, reserve members, retired veterans, and their dependents. Because most TRICARE plan members are currently civilians,3 Dr. Schoenfeld said the study findings are generalizable to the U.S. population.
Included in the study were patients aged 18 to 64 years whose injuries were severe, as indicated by an Injury Severity Score of 9 or higher. Patients with major trauma could be expected to receive opiate prescriptions after their hospitalization, Dr. Schoenfeld explained. In an analysis expanded after submission of the abstract and presented at Clinical Congress, 15,369 patients were included. None of the patients had filled an opiate prescription within six months before their injuries, the investigators reported.
Although more than half of the patients in the study, or 8,282, filled at least one opiate prescription soon after discharge, only 8.9 percent (1,371 patients) continued to fill opiate prescriptions three months later, the investigators reported. Continued prescription opiate use reportedly dropped to 3.9 percent (597 patients) at six months and 1.1 percent (175 patients) at one year.
To identify predictors of continuing use of prescription opiates after hospital discharge, the researchers evaluated patients' demographic and medical factors.
Only a few factors, including older age, increased the chance for long-term use of opiates after the initial prescription, statistical analysis found. Patients ages 45 to 64 were reportedly likelier to continue using prescribed opiates over the one-year study period than were young adults (ages 18 to 24).
Also increasing the probability of continued prescription opiate use were lower socioeconomic status (enlisted junior service members compared with officers) and hospitalization longer than two weeks. Current military rank or the last rank at termination of service was a proxy for socioeconomic status. Military rank is an accepted proxy for socioeconomic status in research because junior enlisted personnel have been found to disproportionately derive from lower socioeconomic backgrounds and have comparable risk factors to civilian peers despite military service, Dr. Schoenfeld noted.
Compared with unmarried patients, those who were married were more likely to still be taking opiate prescriptions long term. However, this finding probably cannot be generalized to the U.S. population, according to Dr. Schoenfeld, because military families tend to marry earlier than civilians do.
Furthermore, he cautioned that the study did not correlate the prolonged use of opiates with physical dependence. The data also did not allow the investigators to assess for inappropriate or illegal use of opiates.
"We wish to emphasize that health care providers should not withhold opiate painkillers because a patient has any of the identified risk factors from this study," Dr. Schoenfeld said. "At-risk patients can benefit from closer follow-up with their health care providers and, for those at high risk, a referral to the hospital's pain management service."Patients with low socioeconomic status might also benefit from referral to a social worker or care manager, he added.
Dr. Schoenfeld's study coauthors, all from Brigham and Women's Hospital, were: Muhammad Ali Chaudhary, MBBS, presented the research findings; Rebecca Scully, MD; Ritam Chowdhury, MBBS, MPH, PhD; Meesha Sharma, MBBS; Juan P. Herrera-Escobar, MD; Cheryl K. Zogg; Elizabeth J. Lilley, MD, MPH; Wei Jiang; and Adil H. Haider, MD, MPH, FACS.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
This study was funded by a grant from the Henry M. Jackson Foundation for the Advancement of Military Medicine Inc.
1 National Institute on Drug Abuse. What are the possible consequences of opioid use and abuse? In: Prescription Drug Abuse Research Report Series. Updated November 2014. Available at: https://www.drugabuse.gov/publications/research-reports/prescription-drugs/opioids/what-are-possible-consequences-opioid-use-abuse. Accessed August 22, 2016.
2 U.S. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on
Drug Use and Health: Summary of National Findings. NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014:59, 64. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. Accessed August 19, 2016.
3 Military Health System and Defense Health Agency. Patients by beneficiary category. Available at: http://health.mil/I-Am-A/Media/Media-Center/Patient-Population-Statistics/Patients-by-Beneficiary-Category. Accessed August 19, 2016.
About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org.