Abstract
The increased use of prescription opioid medications has contributed to an epidemic of sustained opioid use, misuse, and addiction. Adults of working age are thought to be at greatest risk for prescription opioid dependence. To develop a risk score (the Stopping Opioids After Surgery score) for sustained prescription opioid use after surgery in a working-age population using readily available clinical information. In this case-control study, claims from TRICARE (the insurance program of the US Department of Defense) for working-age adult (age 18-64 years) patients undergoing 1 of 10 common surgical procedures from October 1, 2005, to September 30, 2014, were queried. A logistic regression model was used to identify variables associated with sustained prescription opioid use. The point estimate for each variable in the risk score was determined by its β coefficient in the model. The risk score for each patient represented the summed point totals, ranging from 0 to 100, with a lower score indicating lower risk of sustained prescription opioid use. Data were analyzed from September 25, 2018, to February 5, 2019. Exposures were age; race; sex; marital status; socioeconomic status; discharge disposition; procedure intensity; length of stay; intensive care unit admission; comorbid diabetes, liver disease, renal disease, malignancy, depression, or anxiety; and prior opioid use status. The primary outcome was sustained prescription opioid use, defined as uninterrupted use for 6 months following surgery. A risk score for each patient was calculated and then used as a predictor of sustained opioid use after surgical intervention. The area under the curve and the Brier score were used to determine the accuracy of the scoring system and the Hosmer-Lemeshow goodness-of-fit test was used to evaluate model calibration. Of 86 356 patients in the analysis (48 827 [56.5%] male; mean [SD] age, 46.5 [14.5] years), 6365 (7.4%) met criteria for sustained prescription opioid use. The sample used for model generation consisted of 64 767 patients, while the validation sample had 21 589 patients. Prior opioid exposure was the factor most strongly associated with sustained opioid use (odds ratio, 13.00; 95% CI, 11.87-14.23). The group with the lowest scores (<31) had a mean (SD) 4.1% (2.5%) risk of sustained opioid use; those with intermediate scores (31-50) had a mean (SD) risk of 14.9% (6.3%); and those with the highest scores (>50) had a mean (SD) risk of 35.8% (3.6%). This study developed an intuitive and accessible opioid risk assessment applicable to the care of working-age patients following surgery. This tool is scalable to clinical practice and can potentially be incorporated into electronic medical record platforms to enable automated calculation and clinical alerts that are generated in real time.
Highlights
Since the year 2000, the United Sates has experienced an epidemic of prescription opioid use, abuse, and dependence.[1,2,3] With more than 259 million opioid prescriptions issued in 2012, the use of prescription opioid pain medications is 4 times higher than it was in 1999.4,5 While representing less than 5% of the global population, the US population is thought to be responsible for more than 80% of opioid consumption worldwide.[6]
Prior opioid exposure was the factor most strongly associated with sustained opioid use
Development of a Risk Assessment for Sustained Prescription Opioid Use After Surgery clinical practice and can potentially be incorporated into electronic medical record platforms to enable automated calculation and clinical alerts that are generated in real time
Summary
Since the year 2000, the United Sates has experienced an epidemic of prescription opioid use, abuse, and dependence.[1,2,3] With more than 259 million opioid prescriptions issued in 2012, the use of prescription opioid pain medications is 4 times higher than it was in 1999.4,5 While representing less than 5% of the global population, the US population is thought to be responsible for more than 80% of opioid consumption worldwide.[6]. Several studies have worked to identify factors associated with sustained prescription opioid use in the surgical population, their direct impact on clinical practice is limited.[8,9,10,11,12,13,14,15] This is because many of the prognostic factors identified are not accessible at the point of care such that a clinician can rapidly apply them to decision-making. Estimates in smaller samples may be influenced by the prevalence of sustained prescription opioid use within that population, as well as variation in the pretest probability of the outcome. A practical, easy way to calculate the risk of sustained opioid use in patients undergoing surgery is not presently available, to our knowledge. While developing interventions capable of mitigating long-term use remains a priority, we believe that the efficacy of these efforts is predicated on identifying the individuals most likely to become sustained prescription users following surgical interventions
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