Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 154 No. 8 (2024)

Inpatient opioid prescribing patterns and their effect on rehospitalisations: a nested case-control study using data from a Swiss public acute hospital

DOI
https://doi.org/10.57187/s.3391
Cite this as:
Swiss Med Wkly. 2024;154:3391
Published
16.08.2024

Summary

AIMS OF THE STUDY: Opioid prescriptions have increased in Switzerland, even though current guidelines warn of their harms. If opioids for postoperative analgesia are not tapered before hospital discharge, patients are at risk of adverse events such as constipation, drowsiness, dependence, tolerance and withdrawal. The aim of this study was to investigate and quantify the potential association between opioids prescribed at discharge from hospital and rehospitalisation.

METHODS: We conducted a nested case-control study using routinely collected electronic health records from a Swiss public acute hospital. Cases were patients aged 65 years or older admitted between November 2014 and December 2018, with documented opioid administration on the day of discharge and rehospitalisation within 18 or 30 days after discharge. Each case was matched to five controls for age, sex, year of hospitalisation and Charlson Comorbidity Index. We calculated odds ratios for 18-day and 30-day rehospitalisation based on exposure to opioids using a conditional logistic regression adjusted for potential confounders. Secondary analyses included stratifications into morphine-equivalent doses of <50 mg, 50–89 mg and ≥90 mg, and co-prescriptions of gabapentinoids and benzodiazepines.

RESULTS: Of 22,471 included patients, 3144 rehospitalisations were identified, of which 1698 were 18-day rehospitalisations and 1446 were 30-day rehospitalisations. Documented opioid administration on the day of discharge was associated with 30-day rehospitalisation after adjustment for confounders (adjusted odds ratio 1.48; 95% CI 1.25–1.75, p <0.001), while no difference was observed in the likelihood of 18-day rehospitalisation. The combined prescription of opioids with benzodiazepines or gabapentinoids and morphine-equivalent doses >50 mg were rare.

CONCLUSIONS: Patients receiving opioids on the day of discharge were 48% more likely to be readmitted to hospital within 30 days. Clinicians should aim to discontinue opioids started in hospital before discharge if possible. Patients receiving an opioid prescription should be educated and monitored as part of opioid stewardship programmes.

References

  1. Ari M, Alexander JT, Weyer G. Prescribing Opioids for Pain. JAMA. 2023 May;329(20):1789–90. 10.1001/jama.2023.6539 DOI: https://doi.org/10.1001/jama.2023.6539
  2. Levy N, Quinlan J, El-Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, et al. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia. 2021 Apr;76(4):520–36. 10.1111/anae.15262 DOI: https://doi.org/10.1111/anae.15262
  3. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012 Mar;172(5):425–30. 10.1001/archinternmed.2011.1827 DOI: https://doi.org/10.1001/archinternmed.2011.1827
  4. Davies LEM, Koster ES, Damen KFM, et al. Patients’ Perspectives on the Development of Prescription Opioid Use Disorder in Patients with Chronic Non-Cancer Pain. Eur Addict Res 2023.29(2):141–9. https://doi.org/10.1159/000529926 DOI: https://doi.org/10.1159/000529926
  5. Levy N, Lord LJ, Lobo DN. UK recommendations on opioid stewardship. BMJ. 2021 Jan;372:m4901. 10.1136/bmj.m4901 DOI: https://doi.org/10.1136/bmj.m4901
  6. Hooijman MF, Martinez-De la Torre A, Weiler S, Burden AM. Opioid sales and opioid-related poisonings in Switzerland: A descriptive population-based time-series analysis. Lancet Reg Health Eur. 2022 Jun;20:100437. 10.1016/j.lanepe.2022.100437 DOI: https://doi.org/10.1016/j.lanepe.2022.100437
  7. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—united States, 2016. JAMA. 2016 Apr;315(15):1624–45. 10.1001/jama.2016.1464 DOI: https://doi.org/10.1001/jama.2016.1464
  8. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022 Nov;71(3):1–95. 10.15585/mmwr.rr7103a1 DOI: https://doi.org/10.15585/mmwr.rr7103a1
  9. Wertli MM, Held U, Signorell A, Steurer J, Blozik E, Burgstaller JM. Opioid Prescription in Switzerland: Appropriate Comedication use in Cancer and Noncancer Pain. Pain Physician. 2019 Nov;22(6):537–48. 10.36076/ppj/2019.22.537 DOI: https://doi.org/10.36076/ppj/2019.22.537
  10. Woitok BK, Büttiker P, Ravioli S, Funk GC, Exadaktylos AK, Lindner G. Patterns of prescription opioid use in Swiss emergency department patients and its association with outcome: a retrospective analysis. BMJ Open. 2020 Sep;10(9):e038079. 10.1136/bmjopen-2020-038079 DOI: https://doi.org/10.1136/bmjopen-2020-038079
  11. Robinson S, Howie-Esquivel J, Vlahov D. Readmission risk factors after hospital discharge among the elderly. Popul Health Manag. 2012 Dec;15(6):338–51. 10.1089/pop.2011.0095 DOI: https://doi.org/10.1089/pop.2011.0095
  12. El Morabet N, Uitvlugt EB, van den Bemt BJ, van den Bemt PM, Janssen MJ, Karapinar-Çarkit F. Prevalence and Preventability of Drug-Related Hospital Readmissions: A Systematic Review. J Am Geriatr Soc. 2018 Mar;66(3):602–8. 10.1111/jgs.15244 DOI: https://doi.org/10.1111/jgs.15244
  13. Eggli Y, Lécureux E (2020) Potentiell vermeidbare Rehospitalisationen Akutsomatik. Nationaler Vergleichsbericht, BFS-Daten 2018
  14. Higi L, Lisibach A, Beeler PE, Lutters M, Blanc AL, Burden AM, et al. External validation of the PAR-Risk Score to assess potentially avoidable hospital readmission risk in internal medicine patients. PLoS One. 2021 Nov;16(11):e0259864. 10.1371/journal.pone.0259864 DOI: https://doi.org/10.1371/journal.pone.0259864
  15. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel (2023) American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc n/a: https://doi.org/10.1111/jgs.18372 DOI: https://doi.org/10.1111/jgs.18372
  16. Lisibach A, Gallucci G, Benelli V, et al Evaluation of the association of anticholinergic burden and delirium in older hospitalised patients – A cohort study comparing 19 anticholinergic burden scales. Br J Clin Pharmacol n/a: https://doi.org/10.1111/bcp.15432 DOI: https://doi.org/10.1111/bcp.15432
  17. Langan SM, Schmidt SA, Wing K, Ehrenstein V, Nicholls SG, Filion KB, et al. The reporting of studies conducted using observational routinely collected health data statement for pharmacoepidemiology (RECORD-PE). BMJ. 2018 Nov;363:k3532. 10.1136/bmj.k3532 DOI: https://doi.org/10.1136/bmj.k3532
  18. American Cancer Society Basal and Squamous Cell Skin Cancer. https://www.cancer.org/cancer/types/basal-and-squamous-cell-skin-cancer.html. Accessed 18 Jul 2023
  19. Schneeweiss S, Rassen JA, Brown JS, Rothman KJ, Happe L, Arlett P, et al. Graphical Depiction of Longitudinal Study Designs in Health Care Databases. Ann Intern Med. 2019 Mar;170(6):398–406. 10.7326/M18-3079 DOI: https://doi.org/10.7326/M18-3079
  20. Wertli MM, Reich O, Signorell A, Burgstaller JM, Steurer J, Held U. Changes over time in prescription practices of pain medications in Switzerland between 2006 and 2013: an analysis of insurance claims. BMC Health Serv Res. 2017 Feb;17(1):167. 10.1186/s12913-017-2086-6 DOI: https://doi.org/10.1186/s12913-017-2086-6
  21. Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May;189(18):E659–66. 10.1503/cmaj.170363 DOI: https://doi.org/10.1503/cmaj.170363
  22. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. 10.1016/0021-9681(87)90171-8 DOI: https://doi.org/10.1016/0021-9681(87)90171-8
  23. Mamdani M, Sykora K, Li P, Normand SL, Streiner DL, Austin PC, et al. Reader’s guide to critical appraisal of cohort studies: 2. Assessing potential for confounding. BMJ. 2005 Apr;330(7497):960–2. 10.1136/bmj.330.7497.960 DOI: https://doi.org/10.1136/bmj.330.7497.960
  24. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009 Nov;41(4):1149–60. 10.3758/BRM.41.4.1149 DOI: https://doi.org/10.3758/BRM.41.4.1149
  25. R Core Team. (2023) R: A Language and Environment for Statistical Computing. https://www.R-project.org/
  26. Hansen BB, Klopfer SO. Optimal Full Matching and Related Designs via Network Flows. J Comput Graph Stat. 2006;15(3):609–27. 10.1198/106186006X137047 DOI: https://doi.org/10.1198/106186006X137047
  27. Du Z, Hao Y (2022) stddiff: Calculate the Standardized Difference for Numeric, Binary and Category Variables
  28. Aragon TJ, Fay MP, Wollschlaeger D, Omidpanah A (2020) epitools: Epidemiology Tools
  29. Nafziger AN, Barkin RL. Opioid Therapy in Acute and Chronic Pain. J Clin Pharmacol. 2018 Sep;58(9):1111–22. 10.1002/jcph.1276 DOI: https://doi.org/10.1002/jcph.1276
  30. Daoust R, Paquet J, Cournoyer A, Piette É, Morris J, Lessard J, et al. Side effects from opioids used for acute pain after emergency department discharge. Am J Emerg Med. 2020 Apr;38(4):695–701. 10.1016/j.ajem.2019.06.001 DOI: https://doi.org/10.1016/j.ajem.2019.06.001
  31. Kurteva S, Abrahamowicz M, Gomes T, Tamblyn R. Association of Opioid Consumption Profiles After Hospitalization With Risk of Adverse Health Care Events. JAMA Netw Open. 2021 May;4(5):e218782. 10.1001/jamanetworkopen.2021.8782 DOI: https://doi.org/10.1001/jamanetworkopen.2021.8782
  32. Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with the use of morphine and opiates. J Intern Med. 2006 Jul;260(1):76–87. 10.1111/j.1365-2796.2006.01667.x DOI: https://doi.org/10.1111/j.1365-2796.2006.01667.x
  33. Seppala LJ, Petrovic M, Ryg J, Bahat G, Topinkova E, Szczerbińska K, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing. 2021 Jun;50(4):1189–99. 10.1093/ageing/afaa249 DOI: https://doi.org/10.1093/ageing/afaa249
  34. Gomes T, Redelmeier DA, Juurlink DN, Dhalla IA, Camacho X, Mamdani MM. Opioid dose and risk of road trauma in Canada: a population-based study. JAMA Intern Med. 2013 Feb;173(3):196–201. 10.1001/2013.jamainternmed.733 DOI: https://doi.org/10.1001/2013.jamainternmed.733
  35. Herzig SJ, Anderson TS, Jung Y, Ngo L, Kim DH, McCarthy EP. Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: A nationwide cohort study. PLoS Med. 2021 Sep;18(9):e1003804. 10.1371/journal.pmed.1003804 DOI: https://doi.org/10.1371/journal.pmed.1003804
  36. Donzé JD, Williams MV, Robinson EJ, Zimlichman E, Aujesky D, Vasilevskis EE, et al. International Validity of the HOSPITAL Score to Predict 30-Day Potentially Avoidable Hospital Readmissions. JAMA Intern Med. 2016 Apr;176(4):496–502. 10.1001/jamainternmed.2015.8462 DOI: https://doi.org/10.1001/jamainternmed.2015.8462
  37. Blanc AL, Fumeaux T, Stirnemann J, Dupuis Lozeron E, Ourhamoune A, Desmeules J, et al. Development of a predictive score for potentially avoidable hospital readmissions for general internal medicine patients. PLoS One. 2019 Jul;14(7):e0219348. 10.1371/journal.pone.0219348 DOI: https://doi.org/10.1371/journal.pone.0219348
  38. Burgstaller JM, Held U, Signorell A, Blozik E, Steurer J, Wertli MM. Increased risk of adverse events in non-cancer patients with chronic and high-dose opioid use-A health insurance claims analysis. PLoS One. 2020 Sep;15(9):e0238285. 10.1371/journal.pone.0238285 DOI: https://doi.org/10.1371/journal.pone.0238285
  39. Els C, Jackson TD, Kunyk D, Lappi VG, Sonnenberg B, Hagtvedt R, et al. Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 Oct;10(10):CD012509. 10.1002/14651858.CD012509.pub2 DOI: https://doi.org/10.1002/14651858.CD012509
  40. Kalkman GA, Kramers C, van Dongen RT, van den Brink W, Schellekens A. Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study. Lancet Public Health. 2019 Oct;4(10):e498–505. 10.1016/S2468-2667(19)30128-8 DOI: https://doi.org/10.1016/S2468-2667(19)30128-8
  41. Morasco BJ, Yarborough BJ, Smith NX, Dobscha SK, Deyo RA, Perrin NA, et al. Higher Prescription Opioid Dose is Associated With Worse Patient-Reported Pain Outcomes and More Health Care Utilization. J Pain. 2017 Apr;18(4):437–45. 10.1016/j.jpain.2016.12.004 DOI: https://doi.org/10.1016/j.jpain.2016.12.004
  42. Ardeljan LD, Waldfogel JM, Bicket MC, Hunsberger JB, Vecchione TM, Arwood N, et al. Current state of opioid stewardship. Am J Health Syst Pharm. 2020 Apr;77(8):636–43. 10.1093/ajhp/zxaa027 DOI: https://doi.org/10.1093/ajhp/zxaa027
  43. Institute for Safe Medication Practices Canada Opioid Stewardship. https://www.ismp-canada.org/opioid_stewardship/. Accessed 17 Jul 2023