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Figure.
Flow Diagram of Cohort Selection
Flow Diagram of Cohort Selection

Patients who received no opioid prescription within 6 months before index hospitalization were considered to be opioid naive. Patients with burns, toxic effects or late effects of trauma, and foreign body ingested through an orifice injury were excluded. ISS indicates Injury Severity Score.

Table 1.  
Demographic and Case Mix of Opioid-Naive Patients at the Time of Discharge After Traumatic Injury
Demographic and Case Mix of Opioid-Naive Patients at the Time of Discharge After Traumatic Injury
Table 2.  
Incidence of Patients Prescribed Opioids at Discharge
Incidence of Patients Prescribed Opioids at Discharge
Table 3.  
Risk-Adjusted Odds of Opioid Prescription After Hospital Discharge for Traumatic Injury
Risk-Adjusted Odds of Opioid Prescription After Hospital Discharge for Traumatic Injury
Table 4.  
Sensitivity Analysis of Opioid Prescription After Hospital Discharge for Traumatic Injury, Excluding Active-Duty Personnel
Sensitivity Analysis of Opioid Prescription After Hospital Discharge for Traumatic Injury, Excluding Active-Duty Personnel
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Original Investigation
October 2017

Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury

Author Affiliations
  • 1Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Division of Trauma Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 4Uniformed Services University of Health Sciences, Bethesda, Maryland
  • 5Deputy Editor, JAMA Surgery
JAMA Surg. 2017;152(10):930-936. doi:10.1001/jamasurg.2017.1685
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.

Introduction

According to the National Trauma Institute, trauma accounts for 2.3 million hospitalizations annually.1 Pain is a common consequence of injury, and the incidence of pain at hospital discharge in trauma patients has been estimated to be as high as 97%.2 Approximately 57% to 59% of trauma patients experience moderate to severe pain as a result of their injuries.2 Inadequate pain control after trauma is associated with poor quality of life, psychological distress, delayed return to work, and the development of chronic pain syndrome.3-7

Opioids, along with local anesthetics, remain the first-line treatment for acute moderate to severe pain following trauma and surgical interventions associated with traumatic events.8 However, with increased scrutiny and growing concerns regarding opioid use and abuse, there has been a push in the health care field toward greater regulation over prescriptions for opioid pain medications, including those issued to patients who sustain traumatic injuries.9-11

Quiz Ref IDAnecdotally, it is believed that trauma and surgery lead to overuse of narcotic analgesics, which in turn contribute to sustained use.12 Dependence and potential abuse, including the use of heroin, are known sequelae of sustained opioid use.13,14 However, to our knowledge, prescribing practices at the time of discharge following traumatic injury have not been previously explored. To set the stage for further exploration of the association between traumatic injury and sustained opioid use, it is first important to understand baseline prescription practices. Therefore, we sought to evaluate the opioid prescription rate for opioid-naive trauma patients at the time of discharge following trauma and factors associated with receipt of opioids at discharge in a population of American trauma patients.

Methods
Data Source

This study used TRICARE insurance claims data (2006-2013) from the Military Health System Data Repository. TRICARE is the health care program of the US uniformed services that provides health care coverage to 9.5 million active-duty, disabled, and retired military personnel and their dependents through military and civilian hospitals across the United States.15 The program is not responsible for care provided to troops in combat zones or care administered through Veterans Administrations hospitals. Care is administered through 2 parallel systems in TRICARE: one is a network of military hospitals across the United States maintained by the Department of Defense, and the other is civilian hospitals where TRICARE acts as a third-party payer. Full details regarding the means through which health care is administered to beneficiaries and the means through which claims data are collected have been elaborated previously.16,17 TRICARE data have been previously used to study outcomes in several surgical and nonsurgical conditions, and the demographics of this population broadly approximate those of the US population younger than 65 years.17-19 The study protocol was reviewed and approved by Partners Human Research Committee with waiver of informed consent. Data were deidentified.

Study Population

TRICARE claims within the Military Health System Data Repository were queried for adult (18-64 years) patients with a hospitalization for a primary diagnosis of traumatic injury (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9 CM], codes 800-959) between January 1, 2006, and December 31, 2013. Opioid-naive patients, defined as those who did not receive a prescription for opioids in the 6 months preceding the traumatic injury, with enrollment in TRICARE at least 1 year prior to the trauma hospitalization, were included in the study. Patients who died during hospitalization, were Medicare or Medicaid eligible, had a trauma or cancer diagnosis within 6 months before the traumatic injury, or had diagnoses consistent with burns, injury by foreign body entering through an orifice, toxic effects, and late effects of trauma were excluded. Patients transferred to rehabilitation and skilled nursing facilities were also excluded due to lack of medication data.

Variable Definitions

Patients included in the study had their claims records abstracted, including demographic and clinical characteristics, and were used for adjusted analysis. Race was categorized as white, black, Asian, and other based on self-reporting. Age was categorized as 18 to 24, 25 to 34, 35 to 44, and 45 to 64 years. Other demographics included sex, marital status, environment of care (military vs civilian hospital), and geographic regions (South, West, Midwest, and Northeast).

Rank of the sponsoring beneficiary was used as a proxy of socioeconomic status in line with prior research.20-23 Rank was classified as officers, enlisted seniors, enlisted juniors, and others. Enlisted juniors represented a lower socioeconomic stratum, and officers represented the upper socioeconomic stratum. Clinical characteristics included in this analysis were Injury Severity Score (ISS) (<9 [mild] vs ≥9 [moderate-severe], calculated using the ICDPIC program in Stata),24 mechanism of injury (penetrating vs nonpenetrating), modified Charlson Comorbidity Index score25 (0, 1, and >1), length of hospitalization, and history of depression (ICD-9 codes 296.3, 296.82, and 311) or anxiety (ICD-9 code 300.02) within 6 months prior to hospitalization for trauma. In line with prior work, the ISS was dichotomized to characterize patients who had sustained mild compared with moderate/severe injuries.2,4

The Drug Enforcement Administration’s list of schedule II and III opioids was used to query prescription data for the study cohort.26 This list includes, but is not limited to, medications such as oxycodone, hydromorphone, morphine, fentanyl, and methadone.

Statistical Analysis

A total of 3229 (9.6%) patients in the study population had missing race information. The missing data were accounted for by using reweighted estimating equations. This approach has been used in previous studies utilizing large databases and TRICARE data.17,27 In this method, a logistic regression model is applied to predict the likelihood of a given case possessing reported race information. The inverse of the resultant probabilities is then taken as survey weight for complete cases in the final analysis to account for potential bias due to excluding cases with missing race.

The incidence of patients receiving opioids at discharge was calculated. Differences between groups were assessed using the χ2 test in unadjusted bivariate analysis. Multivariable logistic regression was then used to identify factors associated with receipt of opioids at discharge. In a sensitivity test, we repeated all testing in a sample limited to patients who were not active-duty service members. All statistical testing was performed using Stata, version 14.0 (StataCorp), and the level of significance was set at P < .05. Data analysis was performed from June 7 to August 21, 2016.

Results

From 2006 to 2013, 37 265 opioid-naive patients were admitted for a traumatic injury. After applying exclusion criteria, 33 762 individuals were included in the final analysis (Figure). Of these patients, 20 204 had an ISS less than 9, and 13 444 (39.8%) had an ISS greater than or equal to 9 (median, 5; interquartile range, 4-10). The cohort was predominantly young (mean [SD] age, 32.9 [13.3] years), male (80.0%), and white (68.6%). Enlisted seniors (48.2%) and active-duty personnel (64.1%) were the main recipients of trauma care during the study period (Table 1). Most of the patients had no prior comorbidity (93.1%).

Quiz Ref IDAt hospital discharge, 18 338 patients (54.3%) received a prescription for opioids. Older patients and women had higher incidences of opioid prescriptions compared with younger patients and men, respectively, in unadjusted analysis. White, black, and Asian patients were also found to have higher incidences of opioid prescriptions compared with other races. Opioid prescription rates did not differ significantly among patients with different ISS (Table 2). Quiz Ref IDIn risk-adjusted regression analysis, older patients (45-64 vs 18-24: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), married patients (OR, 1.26; 95% CI, 1.20-1.34), and those with a higher ISS (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) had a higher likelihood of opioid prescriptions at discharge. Quiz Ref IDConversely, men (OR, 0.76; 95% CI, 0.69-0.83) and those with a diagnosis of anxiety (OR, 0.82; 95% CI, 0.73-0.93) had a decreased likelihood of opioid prescriptions at discharge (Table 3).

In the sensitivity analysis, we found that married patients (OR, 1.38; 95% CI, 1.19-1.60) were still more likely to be prescribed opioids at trauma discharge; however, older age and ISS lost statistical significance, possibly due to reduced sample size. Similarly, men (OR, 0.78; 95% CI, 0.68-0.89) had a lower likelihood of opioid prescription, and anxiety lost statistical significance (Table 4).

Discussion

The increasing number of people dependent on opioid analgesics is a growing concern in US health care.28 The number of deaths due to opioid abuse and overdose has steadily increased in the past decade, which has led to a call for stricter regulation on the prescription of these drugs.9,11,29 Due to a scarcity of data on the cause of prescription and illegal opioid abuse and patterns of opioid prescription in different clinical contexts, the prescription of opioids by all physicians has come under increased scrutiny.30 Opioids are the first-line treatment for acute moderate to severe pain.8 Our analysis shows that the incidence of patients receiving opioid prescriptions at discharge closely approximates the incidence of patients reporting moderate to severe pain after trauma in previous literature.2,31 Given the higher incidence of acute pain among trauma patients,2,31 as well as a documented need for adequate analgesia,3,31 we believe that this population could be adversely affected by stringent regulations.

Through this study, we evaluated the prescription rate of opioid analgesics at discharge for opioid-naive trauma patients. Quiz Ref IDA total of 54.3% of the patients in this cohort were prescribed opioids at the time of discharge. This incidence closely matches the incidence of trauma patients reporting moderate to severe pain at discharge (57%-59%) in other studies and may serve as an external measure of appropriate utilization of opioids in this population.2,31

Our adjusted analysis demonstrated that older age, marriage, and higher ISS are associated with a greater likelihood of opioid prescription at hospital discharge. The findings regarding age resonate with those of previously published studies looking at the longitudinal use of opioids, which show that older adults are more likely to receive prescription opioids than are their younger counterparts.32,33 The literature on the role of marriage on prescription opioid use demonstrates that, although being married is an indicator of prescription opioid use, being single is associated with opioid dependence and abuse.34,35 We are cautious about making conclusions regarding marital status from this analysis because early marriage is a recognized feature of military culture, and the association between opioid prescription and marital status may be predominantly driven by early marriage in this population.36 Higher injury severity has been linked to a higher likelihood of opioid receipt in the emergency department. Hence, our finding that higher injury severity is associated with an increased likelihood of opioid prescription at discharge is logical.37

Our results also demonstrated that male sex and past diagnosis of anxiety disorders were associated with lower odds of opioid prescription. In previous studies, male sex has been linked to reporting lower severity of pain, which may explain the lower likelihood of opioid prescription at discharge encountered in this analysis.38,39 Previous literature also supports this finding that men are less likely to use prescription opioids.34 We are cautious in the interpretation of our finding regarding the influence of anxiety on opioid prescriptions at discharge due to the stigma associated with mental health problems in the military.40 However, we postulate that this issue may reflect provider concerns regarding opioid dependence in patients with this comorbidity.

To our knowledge, this is the first investigation evaluating factors associated with the receipt of prescription opioids at discharge in a large and diverse population of American trauma patients. Studies like this cannot be accomplished in mainstream national databases, such as the National Inpatient Sample, National Trauma Data Bank, and National Surgical Quality Improvement Program, owing to the unavailability of postdischarge information and medication data. The TRICARE database, with its large number of enrollees and diverse sociodemographic characteristics,17,18 is an invaluable resource for such studies. Moreover, although the population in this study largely comprised active-duty men younger than 35 years, this group has been previously demonstrated to be representative of the American demographic at greatest risk of traumatic injury.17,20

Strengths and Limitations

Notwithstanding the strengths of the study, we recognize that there are limitations. First, this analysis was performed using administrative data. Thus, it lacks nuanced clinical information, such as pain severity, in-hospital opioid use, and the rationale for opioid prescription. The data also limited our ability to assess multimodal pain management strategies and opioid dosage since over-the-counter analgesics were not accounted for in the claims and medication dosage was not reliably coded in the data set. Second, there is the potential that some of the study findings are specific to the military population and might not be generalizable to the US population as a whole. To address this concern, we performed a sensitivity analysis of only non–active-duty patients and found that none of the associations demonstrated in the original analysis changed direction in the sensitivity test, lending further strength to our findings. Furthermore, we emphasize that there is no difference in the diagnostic criteria used for determination of any medical or surgical condition, including anxiety disorders or posttraumatic stress disorder, between military and civilian patients.41,42 Third, there was variability in the reporting of certain variables, such as race. We accounted for missing race information by using a reweighted estimating equation—a method previously used in large database analyses.27 Although this is a robust method to mitigate bias created by missing information, we recognize that some residual bias may persist.

Despite its limitations, this study included a large number of US patients with a demographic profile close to that of the US population at greatest risk of traumatic injury.20,31Although these individuals have some degree of military affiliation, all patients considered in this analysis were injured in the civilian sector; those who sustained combat-related trauma were not included. Our results indicate that only 54.3% of trauma patients were prescribed opioids at discharge, and this number is very close to the incidence of acute moderate to severe pain previously reported in this population. Furthermore, previous work has demonstrated that surgical and trauma patients are unlikely to become sustained opioid users, strengthening the premise that current practices of opioid prescription in this population are safe.12,33

Conclusions

The findings of this study lead us to the conclusion that the utilization of opioid analgesics in this population is appropriate, and any restriction on prescription patterns for these patients may come at the expense of increased pain and decreased quality of care within this population. Going forward, we maintain that the best practices, such as level of pain and injury severity, rather than arbitrary regulations should be used to inform the need for prescription opioid medications at discharge in patients hospitalized for traumatic injury. Future research efforts should focus on accurately identifying patients at the highest risk for dependence, as well as those who could maximally benefit from a short course of prescription opioids without a concomitant increase in the likelihood of abuse.

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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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