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Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury

Educational Objective
To identify the incidence of opioid prescription at discharge in adult military health care beneficiaries having had trauma.
1 Credit CME
Key Points

Question  What is the incidence and predictors of opioid prescription at hospital discharge for patients with traumatic injury?

Findings  In a population-based analysis of military health care beneficiary claims data, 54.3% of the 33 762 patients with traumatic injury received an opioid prescription at discharge. Older age and higher injury severity were significantly associated with a higher likelihood of opioid prescription.

Meanings  The incidence of opioid prescription at discharge for patients with traumatic injury closely approximates the incidence of moderate to severe pain reported in this population, indicating appropriate prescribing practices.

Abstract

Importance  In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored.

Objective  To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort.

Design, Setting, and Participants  Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration’s list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016.

Exposures  Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors.

Main Outcomes and Measures  Prescription of opioid analgesics at discharge.

Results  Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge.

Conclusions and Relevance  The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain—not arbitrary regulations—should inform the decision to prescribe opioids.

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Article Information

Accepted for Publication: April 1, 2017.

Corresponding Author: Muhammad Ali Chaudhary, MD, Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Ste 4-020, Boston, MA 02120 (mchaudhary@bwh.harvard.edu).

Published Online: June 21, 2017. doi:10.1001/jamasurg.2017.1685

Author Contributions: Dr Chaudhary had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Chaudhary, Schoenfeld, Chowdhury, Sharma, Nitzschke, Koehlmoos, Haider.

Acquisition, analysis, or interpretation of data: Chaudhary, Schoenfeld, Harlow, Ranjit, Scully, Nitzschke, Koehlmoos, Haider.

Drafting of the manuscript: Chaudhary, Schoenfeld, Scully, Sharma, Haider.

Critical revision of the manuscript for important intellectual content: Schoenfeld, Harlow, Ranjit, Chowdhury, Sharma, Nitzschke, Koehlmoos, Haider.

Statistical analysis: Chaudhary, Ranjit, Scully, Sharma.

Obtained funding: Koehlmoos, Haider.

Administrative, technical, or material support: Schoenfeld, Chowdhury, Koehlmoos, Haider.

Supervision: Schoenfeld, Nitzschke, Haider.

Conflict of Interest Disclosures: No disclosures were reported.

Funding/Support: This project was funded in part by grant HU0001-11-1-0023 from the Henry M. Jackson Foundation for the Advancement of Military Medicine. Drs Chaudhary, Schoenfeld, Ranjit, Chowdhury, Sharma, Koehlmoos, and Haider receive partial salary support from this grant.

Role of the Funder/Sponsor: The Henry Jackson Foundation was not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Haider is Deputy Editor of JAMA Surgery but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

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