- Email: [email protected]
Outpatient opioid use of burn patients: A retrospective review
JBUR 5856 No. of Pages 6
burns xxx (2019) xxx –xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Outpatient opioid use of burn patients: A retrospective review Haig A. Yenikomshian a, * ,1 , Eleanor E. Curtis b,1 , Gretchen J. Carrougher b,1 , Qian Qiu c,1 , Nicole S. Gibran b,1 , Samuel P. Mandell b,1 a
University of Southern California, Division of Plastic and Reconstructive Surgery, Los Angeles, CA, USA University of Washington, Department of Surgery, Seattle, WA, USA c Harborview Injury and Prevention and Research Center, Seattle, WA, USA b
article info
abstract
Article history:
Introduction: Opioid overuse is a growing patient safety issue but continue to be integral to
Available online xxx
burn pain management. This study aims to characterize opioid use in discharged patients and factors for predictive of long term use. Methods: Participants with burns admitted to a single center from 2006 to 2015 were included.
Keywords:
Total outpatient morphine equivalent dose (MED) was recorded at discharge and each clinic
Opioid
visit. Burn size, percent grafted, age, sex, and preadmission drug use were collected. For each
Pain management
time point, multivariate logistic regression was performed to examine the relationship of
Opioid abuse
discharge MED and long-term opioid use, adjusting for age, sex, burn size, and percent
Outpatient care
grafted. MED was divided into low (0–150 mg per day), medium (151–300 mg per day), and high (greater than 301 mg) groups on day of discharge. Results: At discharge, 366 (90%) patients received opioids. At day 14, both the medium MED (OR 2.72; CI 1.18–6.23) and high MED (OR 2.74; CI 1.02–7.37) groups had an increased risk for continued opioid use. On day 60, only the high MED group (OR 6.06; CI 1.60–22.97) had an increased risk. History of drug use was significant at 60 days (OR 7.67; 1.67–35.26) and alcohol use was significant at 14 days (OR 3.14; CI 1.25–7.93) and 30 days (OR 5.92; CI 1.81–19.36). Conclusions: Whereas opioids are widely prescribed upon discharge, most patients no longer use them 30 days later. Higher opiate utilization at discharge increases risk of long term use, as does pre-injury drug and alcohol use, but only temporarily. © 2019 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Opioid overuse in the United States is an increasing problem. Approximately 2 million people are reported to abuse
prescription drugs [1]. In 2015, the Center for Disease Control reported approximately 33,000 deaths in the country due to opioid overuse [2]. As this becomes more of a national crisis, healthcare providers are focusing more on the amount of analgesics prescribed to patients particularly in the less
* Corresponding author at: 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033 USA. E-mail address: [email protected] (H.A. Yenikomshian). 1 Main address: UW Medicine Regional Burn Center, Department of Surgery, Harborview Medical Center, 325 9th Avenue, Box 359796, Seattle, WA, USA 98104. https://doi.org/10.1016/j.burns.2019.05.019 0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: H.A. Yenikomshian, et al., Outpatient opioid use of burn patients: A retrospective review, Burns (2019), https://doi.org/10.1016/j.burns.2019.05.019
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monitored, outpatient setting. At the same time, opioid medication continues to be the main form of analgesia in an inpatient setting. This presents a particularly difficult challenge in the burn population as opioids are the main class of treatment of pain. Patients with burns severe enough for inpatient admission are often prescribed large amounts of pain medications during their convalescence. While there have been new treatment modalities to reduce the amount of opioids such as around the clock non-steroidal anti-inflammatory drugs (NSAIDs), which have reduced the amount of opioids, they continue to be necessary [3]. As patients are discharged from the hospital, most patients with open wounds are prescribed opioids and some patients can remain on these for months afterwards [4]. The goal of this study was to evaluate opioid use in the outpatient population. Particularly, to see which patients continue on opioids for long periods of time and to determine any preadmission or discharge factors associated with chronic use after-burn.
2.
Materials and methods
2.1.
Demographics
This is a retrospective cohort study which analyzed patients over the age of 14 years with burn injuries admitted to a single, regional burn center with flame, scald, contact, chemical, or electrical burns between 2006 and 2016. Information was collected from the Burn Model System (BMS) National Database and approval from the University of Washington Institutional Review Board (IRB) was obtained. This database included patients 14 years and older who met one of the following criteria: burn size greater than 20% total body surface area (TBSA), 10% TBSA burn for those age 65 and greater, injuries involving the face, hands, neck, or feet, and any high voltage electrical injury. Starting in 2009, surgical intervention for wound closure was a necessary criterion. Within these patients, demographic data for age, sex, and self-reported history of alcohol and drug abuse was recorded. Hospital data for total body surface area (TBSA) burn and TBSA grafted, outpatient opioid prescriptions were also collected from the patient's medical records. All patients in the BMS were included over this 10-year period.
2.2.
Outcomes and assessments
Due to the variability of opioids prescribed, all medications were converted to morphine equivalent dose (MED) for better comparison using the Washington State Agency Medical Directors’ Group calculator (Agency Medical Director’s Group, Olympia, Washington). On day of discharge, all recorded opioid use was recorded and converted into MED. Patients were then categorized into one of three groups based on the amount of MED prescribed on day of discharge: low (0–150 mg) MED, medium (151–300 mg) MED and high (greater than 301 mg) MED. Outpatient visits were examined and categorized to day 7, 14, 30, 60, 90, 180, and 365, based on nearest day since discharge. Patient reported opioid intake was recorded and converted to MED. The last clinic visit where patients no longer reported opioid use was recorded.
2.3.
Statistical methods
Patient demographic characteristics were compared by levels of morphine equivalent doses (MED) at discharge. Mean (SD) or median (IQR) were reported for continuous factors, while percentage (%) were used for categorical factors. Percentage of patients sticking with opioids usage at specific time point after discharge was also reported by three MED levels. For each time point, multivariate logistic regression analysis was used to examine the relationship of opioid usage and MED levels, adjusting for age, sex, TBSA burn, TBSA grafted, history of drug abuse, and history of alcohol abuse. Data were analyzed using STATA 13.0 (StataCorp LLC, College Station, TX).
3.
Results
3.1.
Demographics
From the Burn Model System database, 409 patient charts were reviewed for this study (Table 1). Mean age for the cohort was 45 (SD 16.2). 308 patients (75%) were male and 101 (25%) female. Median TBSA% was 18 (IQR: 5–28) and median TBSA% grafted was 5 (IQR:2–17).
3.2.
Day of discharge opioid usage
On the day of discharge 366 participants (90%) were prescribed opioids. The characteristics for these patients are shown in Table 1. The low MED group had the largest number of patients with 228 individuals (56%). The medium MED group consisted of 126 individuals (31%). Finally, the high MED group was the smallest with 55 individuals (14%).
3.3.
Follow-up opioid usage
Table 2 outlines the percent of participants who reported taking opioids on the follow up clinic visits. For the entire cohort, opioid usage decreased with time and by day 30, only 30% of individuals reported using opioids. By day 90, only 14% of participants reported using opioids. After this, the percentage of patients remaining on opioids remained relatively flat. Fig. 1 shows the percent of participants off of opioids over time broken down by morphine equivalent dose groups. Different MED groups and opioid use were then analyzed. Table 3 outlines the breakdown of the different MED groups opioid usage based on days since discharge. At day 14, both the medium MED (OR 2.72; CI 1.18–6.23) and high MED (OR 2.74; CI 1.02–7.37) groups had an increased risk for continued opioid use. On day 60, the high MED group (OR 6.06; CI 1.60–22.97) had an increase risk. There was no increased risk after day 60. Patient demographics did not affect opioid usage as an outpatient. At no time point, were age and sex contributing factors for long term opioid use and were not statistically significant. Similarly, percent TBSA burn and grafted did not influence the likelihood of being on opioids after discharge. The odds ratios and confidence intervals for drug and alcohol abuse prior to admission is shown on Table 4. On analysis of drug use history prior to admission, day 90 was significant for drug use (OR 7.67; 1.67–35.26) but at no other time
Please cite this article in press as: H.A. Yenikomshian, et al., Outpatient opioid use of burn patients: A retrospective review, Burns (2019), https://doi.org/10.1016/j.burns.2019.05.019
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Table 1 – Patient demographic breakdown between the different morphine equivalent doses at discharge. Low MED dose at discharge (0–150)a
All patients # (%) of patients Age in years, mean[SD] Burn size in %TBSA, media[IQR] Burn size in % TBSA grafted, median[IQR] %Male a
Medium MED dose at discharge (151–300)a
High MED dose at discharge (>300)a
409 45[16.2] 18[5–28] 5 [2–17]
228 (56%) 47[17.6] 11[4–25] 3 [1–14]
126 (31%) 44[14.0] 15[7–29] 6 [2–17]
55 (14%) 40[13.7] 18[8–35] 9[4–22]
308 (75%)
72
80
76
MED dose at discharge was calculated as morphine equivalent does.
Table 2 – Patient breakdown based on morphine equivalent dose (MED).
Number of patients Taking opioids at 7 days (%) Taking opioids at 14 days (%) Taking opioids at 30 days (%) Taking opioids at 60 days (%) Taking opioids at 90 days (%) Taking opioids at 180 Days (%) Taking Opioids at 365 days (%) a
All patients
Low MED at discharge (0–50)a
Medium MED at Discharge (151–300)a
High MED at discharge (>300)a
409 68 60 30 18 14 9 8
228 (56%) 66 51 28 11 11 10 13
126 (31%) 67 73 32 25 14 5 5
55 (14%) 80 74 46 41 30 11 7
MED dose at discharge was calculated as morphine equivalent dose.
Fig. 1 – Percent of patients using opioids over time.
Table 3 – The odds ratio of being on opioids at a set time period of the medium morphine equivalent dose (MED) and high MED compared to the low MED group. Day 14 Days 30 Days 60 Days 90 Days 365 Days a *
Medium MED at discharge (151–300)a aOR (95% CI)
High MED at discharge (>300)a aOR (95% CI)
2.72 (1.18–6.23)* 0.91 (0.41–1.99) 3.02 (0.99–9.18) 1.05 (0.28–3.90) 1.44 (0.08–25.01)
2.74 (1.02–7.37)* 1.38 (0.49–3.93) 6.06 (1.60–22.97)* 2.69 (0.64–11.30) 2.56 (0.09–74.30)
MED dose at discharge was calculated as morphine equivalent does. p <0.05.
Please cite this article in press as: H.A. Yenikomshian, et al., Outpatient opioid use of burn patients: A retrospective review, Burns (2019), https://doi.org/10.1016/j.burns.2019.05.019
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Table 4 – The odds ratio and 95% confidence intervals of drug and alcohol use as a predicting factor for being on opioids at a specific clinic visit. History of drug abuse History of alcohol abuse aOR (95% CI) aOR (95% CI) 14 Days 30 Days 60 Days 90 Days 365 Days *
2.86 0.75 1.11 7.67 4.97
(0.69–11.88) (0.22–2.59) (0.22–5.47) (1.67–35.26)* (0.17–145.13)
1.23 (0.45–3.35) 3.14 (1.25–7.93)* 5.92 (1.81–19.36)* 2.89 (0.80–10.42) 12.46 (0.72–215.00)
p <0.05.
point was there a statistical significance. For patients with preinjury alcohol abuse at 30 days there was an increased risk of being on opioids (OR 3.14; CI 1.25–7.93). This risk continued at 60 days (OR 5.92; CI 1.81–19.36), but then was not significant thereafter.
4.
Discussion
The purpose of this study was to characterize the outpatient opioid use of burn patients as well as predictive factors for long term use. Practitioners have become more cognizant of prescription patterns as opioid abuse has increased. At the same time, state and federal governments have also increased pressure on doctors to decrease the amounts of opioid prescribed. For instance, The State of Washington Medicaid Program has restricted the prescribing practices of clinicians limiting the total daily MED amount to 90 with specific exemptions [5]. The State recommends prescribing medication for a total of only 7 days and patients requesting opioid pain medication longer than three months to be assessed by a pain management specialist [6]. According to the Center for Disease Control, doses above 50 MED are considered high [7]. These stricter criteria present a challenge for burn pain management as these levels are often exceeded in order to control pain. From our data, many patients who received high doses of opioids would be off them by 14 days but are incorrectly categorized as “high risk” by the new state and federal definitions. Opioids will continue to be the main class of medication for post-discharge pain management for burn survivors due to the effectiveness and versatility [8]. Different routes and half-lives allow for medications which are useful for background pain, procedural pain, and breakthrough pain in both sedated and awake patients [9]. Another benefit of adequate pain control is improved outcomes decreasing morbidity of patients after discharge. When patients have better pain control they have less incidence of post-traumatic stress disorder and better functional outcomes [10]. Pain treatment is necessary even after a patient’s wounds have “healed,” and still remains an important part of burn care. A vast majority of patients were still prescribed opioid pain medication at the day of discharge but tapered off of use by 90 days. Interestingly, those patients who were on opioids at 90 days were more likely to be on them at one year. This is similar to a study from Salas et al. which looked at a general
cohort of patients and tracked opioid use. Patients who were prescribed opioids at 90 days in this study also had a high risk of being on opioids long term [11]. Even if burns are healed and grafted they are still painful. Months after injury, patients complain of significant neuropathic pain, itch, and a generalized ache. In a study by Choinière et al. 82% of patients experiences neuropathic pain at one year and 35% complained of pain in the scarred tissue [12]. Browne et al. showed that patients with higher pain medication utilisation in an outpatient setting also had higher rates of depression and anxiety [13]. In a survey of burn survivors by Dauber et al., chronic outpatient pain interfered with daily living 55% of the time. Clearly, pain management still is a tremendous problem for outpatient burn care months after injury. Burn providers must now focus on different treatment modalities, both pharmacological and nonpharmacological for adequate outpatient pain control. Approximately 10% of patients will remain on opioids at one year. Other studies which involve non-burn patients have demonstrated similar levels suggesting that even though burn patients received higher initial doses long term risk may not be elevated [14]. When examining the data for predictive factors for chronic use little of the data was significant. Patients who were on medium and high doses of opioids were more likely to be on opioids at two weeks, but this was not surprising as patients are usually weaned down at a steady rate to prevent withdrawal. The higher MED group still had a statistically significant chance of being on opioids at day 60 but not significant after that. Even with high doses at day of discharge patients managed to wean off of these medications quickly and did not become chronic users. There continued to be a large percentage of patients in the Low MED group who were on opioid medications at day 365 but did not find any statistically significant risks factors associated with this group. Other factors examined also did little to impact opioid use. When examining age or sex, there was no significance for use of medications. Other studies have also shown no clinical significance. Thielke et al. examined two large American health systems and found no predictive factors for chronic opioid use based off of age or sex [15]. Malenfant et al. examined long term chronic sensory problems in burn patients and found no difference in either of these two demographic variables or in TBSA burned areas either [16]. Data on TBSA grafted is limited on whether patients used more opioids long term. This variable, as well as total TBSA burn size was used as a marker for the severity of the burn. One reason these patients might not have been on opioids long term in an outpatient setting is that these patients may have stayed in the hospital for a longer duration and begun their opioid tapers in house. Previous history of drug and alcohol abuse is a known risk factor for opioid misuse [17]. In our study, patients who endorsed a history of drug abuse were more likely to be on opioids at day 90 but this was not significant for other time points. Alcohol was also predictive at 30 and 60 days but again was not significant after. Sullivan et al. when studying commercial and Medicaid insurance plans did find a positive correlation of opioid abuse and substance dependence [18]. This conflicting data demonstrates one of the limitations of our study. Drug and alcohol dependence was based off of selfreported questionnaires and patients may have decided to not
Please cite this article in press as: H.A. Yenikomshian, et al., Outpatient opioid use of burn patients: A retrospective review, Burns (2019), https://doi.org/10.1016/j.burns.2019.05.019
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answer truthfully. Another issue is our study focused on prescribed and recorded opioid use by patients. Those who were obtaining multiple prescriptions from outside sources or through illegal means would have unreported usage of opioids. Another limitation in our study was the lack of standardization in weaning regimens or type of medications used in our patient population. This made it difficult to standardize patient’s pain medication use and weaning plans. Our center is fairly homogenous in opioid prescribing and will only give medications if a patient complains of significant pain that is altering his/her daily living or uses pain medication for daily wound care. Over the 10-year period of the study, practices in opioid prescriptions may have changed which was not effectively captured in the cohort. For example, there has been a growing emphasis on multimodal therapy with other classes of medications such as gabapentin, acetaminophen, and NSAIDs. For instance, if a patient complains of neuropathic pain or itch, gabapentin is now routinely prescribed as a first line treatment. These adjunct medications may affect the use and amount of opioid medications. The lack of standardization is not limited to our burn center but there is significant practice variability nationally and internationally on the treatment of outpatient pain regimens [19]. A standardization would enable all patients to be on the same algorithm and help to spot those patients who are still using opioid pain medications long term.
5.
Conclusion
Clearly there is a patient population of around 10% who become chronic users which we found in our patient population as well as validated in other studies including other burn cohorts [20]. The predisposing factors of who is at risk for long term risk is difficult to ascertain. Age, sex, and amount of opioids used at discharge did not affect long term use. Previous drug and alcohol use also did not affect patients after 90 days. Clearly new screening tools have to be developed to better identify these patients early [21]. Through this, patients predisposed to opioid dependence and abuse can receive earlier interventions to prevent long term use and overall use of an effective but dangerous medication can be reduced.
Authors roles and preparation of this manuscript All listed authors have provided (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; (3) final approval of the version to be published; (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Statement of institutional review board The following study has been approved by the University of Washington Institutional Review Board (IRB).
5
Conflict of interest There are no conflicts of interest for any authors.
Funding The contents of this manuscript were developed under a grant from the National Institute on Disability and Rehabilitation Research (NIDILRR grant #90DP0029). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this manuscript do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. REFERENCES
[1] American Society of Addiction Medicine. Opioid addiction 2016 Facts and Figures. https://www.asam.org/docs/defaultsource/advocacy/opioid-addiction-disease-facts-figures.pdf. (Accessed 3 January 2018). [2] Centers for Disease Control and Prevention. Opioid Overdose. https://www.cdc.gov/drugoverdose/index.html. (Accessed 3 January 2018). [3] Marret E, Kurdi O, Zufferey P, Bonnet F. Effects of nonsteroidal anti-inflammatory drugs on patient controlled analgesia morphine side effects: meta-analysis of randomized controlled trials. Anesthesiology 2005;102:1249–60. [4] Wibbenmeyer L, Otrogge K, Kluesner K, Zimmerman MB, Kealey PG. An evaluation of discharge opioid prescribing practices in a burn population. J Burn Care Res 2015;(36):329–35. [5] Washington State Health Care Authority. Opioid clinical policy– medicaid. Effective 2017. October 1, https://www.hca. wa.gov/billers-providers-partners/programs-and-services/ opioids. (Accessed 16 January 2019). [6] Washington State Health Care Authority News Release Thursday, October 26, 2017. https://www.hca.wa.gov/abouthca/hca-implement-opioid-clinical-policy-apple-healthmedicaid-nov-1 (accessed 16 January 2019). [7] Dowell D, Haegerich TM, Chou R. CDC guidelines for prescribing opioids for chronic pain – United States 2016. MMWR Recomm Rep 2016;65:1–49. [8] Richardson P, Mustard L. The management of pain in the burns unit. Burns 2009;35:921–36. [9] Patterson DR, Hoflund H, Espey K, Sharar S. Pain management. Burns 2004;30:A10–5. [10] Saxe G, Stoddard F, Courtney D, Cunningham K, Chawla N, Sheridan R, et al. Relationship between acute morphine and the course of post traumatic stress disorder in children with burns. J Am Acad Child Adolesc Psychiatry 2001;40:915–21. [11] Salas J, Scherrer JF, Ahmedani BK, Copeland LA, Bucholz KK, Sullivan MD, et al. Gender and the association between longterm prescription opioid use and new-onset depression. Pain 2018;19(1):88–98. [12] Choiniere M, Melzack R, Paillon J. Pain and paresthesia in patients with healed burns: an exploratory study. J Pain Symptom Manage 1991;6(7):437–44. [13] Browne AL, Andrews R, Schug SA, Wood F. Persistent pain outcomes and patient satisfaction with pain management after burn injury. Clin J Pain 2011;27(2):136–45. [14] Parsells KJ, Cook SF, Kaufman DW, Anderson T, Rosenberg L, Mitchell AA. Prevalence and characteristics of opioid use in the U.S. Adult population. Pain 2008;138(3):508–13.
Please cite this article in press as: H.A. Yenikomshian, et al., Outpatient opioid use of burn patients: A retrospective review, Burns (2019), https://doi.org/10.1016/j.burns.2019.05.019
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[15] Thielke SM, Simoni-Wastila L, Edlund MJ, DeVries A, Martin BC, Braden JB, et al. Age and sex trends in long-term opioid use in two large American health systems between 2000–2005. Pain Med 2010;11:248–56. [16] Malenfant A, Forget R, Papillon J, Amsel R, Frigon JY, Choiniere M. Prevalence and characteristics of chronic sensory problems in burn patients. Pain 1996;67:493–500. [17] Edlund MJ, Martin BC, Fan MY, Devries A, Braden JB, Sullivan MD. Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study. Drug Alcohol Depend 2010;112:90–8. [18] Sullivan MD, Edlund MJ, Fan MY, DeVries A, Braden JB, Martin BC. Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and
medicaid insurance plans: the TROUP study. Pain 2010;150:332–9. [19] Gamst-Jensen H, Vedel PN, Lindberg-Larsen VO, Egerod I. Acute pain management in burn patients: appraisal and thematic analysis of four clinical guidelines. Burns 2014;40:1463–9. [20] Wibbenmeyer L, Otrogge K, Kluesner K, Zimmerman MB, Kealey PG. An evaluation of discharge opioid prescribing practices in a burn population. J Burn Care Res 2015;(36): 329–35. [21] Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain 2008;24(6):497–508.
Please cite this article in press as: H.A. Yenikomshian, et al., Outpatient opioid use of burn patients: A retrospective review, Burns (2019), https://doi.org/10.1016/j.burns.2019.05.019
burns xxx (2019) xxx –xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Outpatient opioid use of burn patients: A retrospective review Haig A. Yenikomshian a, * ,1 , Eleanor E. Curtis b,1 , Gretchen J. Carrougher b,1 , Qian Qiu c,1 , Nicole S. Gibran b,1 , Samuel P. Mandell b,1 a
University of Southern California, Division of Plastic and Reconstructive Surgery, Los Angeles, CA, USA University of Washington, Department of Surgery, Seattle, WA, USA c Harborview Injury and Prevention and Research Center, Seattle, WA, USA b
article info
abstract
Article history:
Introduction: Opioid overuse is a growing patient safety issue but continue to be integral to
Available online xxx
burn pain management. This study aims to characterize opioid use in discharged patients and factors for predictive of long term use. Methods: Participants with burns admitted to a single center from 2006 to 2015 were included.
Keywords:
Total outpatient morphine equivalent dose (MED) was recorded at discharge and each clinic
Opioid
visit. Burn size, percent grafted, age, sex, and preadmission drug use were collected. For each
Pain management
time point, multivariate logistic regression was performed to examine the relationship of
Opioid abuse
discharge MED and long-term opioid use, adjusting for age, sex, burn size, and percent
Outpatient care
grafted. MED was divided into low (0–150 mg per day), medium (151–300 mg per day), and high (greater than 301 mg) groups on day of discharge. Results: At discharge, 366 (90%) patients received opioids. At day 14, both the medium MED (OR 2.72; CI 1.18–6.23) and high MED (OR 2.74; CI 1.02–7.37) groups had an increased risk for continued opioid use. On day 60, only the high MED group (OR 6.06; CI 1.60–22.97) had an increased risk. History of drug use was significant at 60 days (OR 7.67; 1.67–35.26) and alcohol use was significant at 14 days (OR 3.14; CI 1.25–7.93) and 30 days (OR 5.92; CI 1.81–19.36). Conclusions: Whereas opioids are widely prescribed upon discharge, most patients no longer use them 30 days later. Higher opiate utilization at discharge increases risk of long term use, as does pre-injury drug and alcohol use, but only temporarily. © 2019 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Opioid overuse in the United States is an increasing problem. Approximately 2 million people are reported to abuse
prescription drugs [1]. In 2015, the Center for Disease Control reported approximately 33,000 deaths in the country due to opioid overuse [2]. As this becomes more of a national crisis, healthcare providers are focusing more on the amount of analgesics prescribed to patients particularly in the less
* Corresponding author at: 1510 San Pablo St. Suite 415, Los Angeles, CA, 90033 USA. E-mail address: [email protected] (H.A. Yenikomshian). 1 Main address: UW Medicine Regional Burn Center, Department of Surgery, Harborview Medical Center, 325 9th Avenue, Box 359796, Seattle, WA, USA 98104. https://doi.org/10.1016/j.burns.2019.05.019 0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: H.A. Yenikomshian, et al., Outpatient opioid use of burn patients: A retrospective review, Burns (2019), https://doi.org/10.1016/j.burns.2019.05.019
JBUR 5856 No. of Pages 6
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monitored, outpatient setting. At the same time, opioid medication continues to be the main form of analgesia in an inpatient setting. This presents a particularly difficult challenge in the burn population as opioids are the main class of treatment of pain. Patients with burns severe enough for inpatient admission are often prescribed large amounts of pain medications during their convalescence. While there have been new treatment modalities to reduce the amount of opioids such as around the clock non-steroidal anti-inflammatory drugs (NSAIDs), which have reduced the amount of opioids, they continue to be necessary [3]. As patients are discharged from the hospital, most patients with open wounds are prescribed opioids and some patients can remain on these for months afterwards [4]. The goal of this study was to evaluate opioid use in the outpatient population. Particularly, to see which patients continue on opioids for long periods of time and to determine any preadmission or discharge factors associated with chronic use after-burn.
2.
Materials and methods
2.1.
Demographics
This is a retrospective cohort study which analyzed patients over the age of 14 years with burn injuries admitted to a single, regional burn center with flame, scald, contact, chemical, or electrical burns between 2006 and 2016. Information was collected from the Burn Model System (BMS) National Database and approval from the University of Washington Institutional Review Board (IRB) was obtained. This database included patients 14 years and older who met one of the following criteria: burn size greater than 20% total body surface area (TBSA), 10% TBSA burn for those age 65 and greater, injuries involving the face, hands, neck, or feet, and any high voltage electrical injury. Starting in 2009, surgical intervention for wound closure was a necessary criterion. Within these patients, demographic data for age, sex, and self-reported history of alcohol and drug abuse was recorded. Hospital data for total body surface area (TBSA) burn and TBSA grafted, outpatient opioid prescriptions were also collected from the patient's medical records. All patients in the BMS were included over this 10-year period.
2.2.
Outcomes and assessments
Due to the variability of opioids prescribed, all medications were converted to morphine equivalent dose (MED) for better comparison using the Washington State Agency Medical Directors’ Group calculator (Agency Medical Director’s Group, Olympia, Washington). On day of discharge, all recorded opioid use was recorded and converted into MED. Patients were then categorized into one of three groups based on the amount of MED prescribed on day of discharge: low (0–150 mg) MED, medium (151–300 mg) MED and high (greater than 301 mg) MED. Outpatient visits were examined and categorized to day 7, 14, 30, 60, 90, 180, and 365, based on nearest day since discharge. Patient reported opioid intake was recorded and converted to MED. The last clinic visit where patients no longer reported opioid use was recorded.
2.3.
Statistical methods
Patient demographic characteristics were compared by levels of morphine equivalent doses (MED) at discharge. Mean (SD) or median (IQR) were reported for continuous factors, while percentage (%) were used for categorical factors. Percentage of patients sticking with opioids usage at specific time point after discharge was also reported by three MED levels. For each time point, multivariate logistic regression analysis was used to examine the relationship of opioid usage and MED levels, adjusting for age, sex, TBSA burn, TBSA grafted, history of drug abuse, and history of alcohol abuse. Data were analyzed using STATA 13.0 (StataCorp LLC, College Station, TX).
3.
Results
3.1.
Demographics
From the Burn Model System database, 409 patient charts were reviewed for this study (Table 1). Mean age for the cohort was 45 (SD 16.2). 308 patients (75%) were male and 101 (25%) female. Median TBSA% was 18 (IQR: 5–28) and median TBSA% grafted was 5 (IQR:2–17).
3.2.
Day of discharge opioid usage
On the day of discharge 366 participants (90%) were prescribed opioids. The characteristics for these patients are shown in Table 1. The low MED group had the largest number of patients with 228 individuals (56%). The medium MED group consisted of 126 individuals (31%). Finally, the high MED group was the smallest with 55 individuals (14%).
3.3.
Follow-up opioid usage
Table 2 outlines the percent of participants who reported taking opioids on the follow up clinic visits. For the entire cohort, opioid usage decreased with time and by day 30, only 30% of individuals reported using opioids. By day 90, only 14% of participants reported using opioids. After this, the percentage of patients remaining on opioids remained relatively flat. Fig. 1 shows the percent of participants off of opioids over time broken down by morphine equivalent dose groups. Different MED groups and opioid use were then analyzed. Table 3 outlines the breakdown of the different MED groups opioid usage based on days since discharge. At day 14, both the medium MED (OR 2.72; CI 1.18–6.23) and high MED (OR 2.74; CI 1.02–7.37) groups had an increased risk for continued opioid use. On day 60, the high MED group (OR 6.06; CI 1.60–22.97) had an increase risk. There was no increased risk after day 60. Patient demographics did not affect opioid usage as an outpatient. At no time point, were age and sex contributing factors for long term opioid use and were not statistically significant. Similarly, percent TBSA burn and grafted did not influence the likelihood of being on opioids after discharge. The odds ratios and confidence intervals for drug and alcohol abuse prior to admission is shown on Table 4. On analysis of drug use history prior to admission, day 90 was significant for drug use (OR 7.67; 1.67–35.26) but at no other time
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Table 1 – Patient demographic breakdown between the different morphine equivalent doses at discharge. Low MED dose at discharge (0–150)a
All patients # (%) of patients Age in years, mean[SD] Burn size in %TBSA, media[IQR] Burn size in % TBSA grafted, median[IQR] %Male a
Medium MED dose at discharge (151–300)a
High MED dose at discharge (>300)a
409 45[16.2] 18[5–28] 5 [2–17]
228 (56%) 47[17.6] 11[4–25] 3 [1–14]
126 (31%) 44[14.0] 15[7–29] 6 [2–17]
55 (14%) 40[13.7] 18[8–35] 9[4–22]
308 (75%)
72
80
76
MED dose at discharge was calculated as morphine equivalent does.
Table 2 – Patient breakdown based on morphine equivalent dose (MED).
Number of patients Taking opioids at 7 days (%) Taking opioids at 14 days (%) Taking opioids at 30 days (%) Taking opioids at 60 days (%) Taking opioids at 90 days (%) Taking opioids at 180 Days (%) Taking Opioids at 365 days (%) a
All patients
Low MED at discharge (0–50)a
Medium MED at Discharge (151–300)a
High MED at discharge (>300)a
409 68 60 30 18 14 9 8
228 (56%) 66 51 28 11 11 10 13
126 (31%) 67 73 32 25 14 5 5
55 (14%) 80 74 46 41 30 11 7
MED dose at discharge was calculated as morphine equivalent dose.
Fig. 1 – Percent of patients using opioids over time.
Table 3 – The odds ratio of being on opioids at a set time period of the medium morphine equivalent dose (MED) and high MED compared to the low MED group. Day 14 Days 30 Days 60 Days 90 Days 365 Days a *
Medium MED at discharge (151–300)a aOR (95% CI)
High MED at discharge (>300)a aOR (95% CI)
2.72 (1.18–6.23)* 0.91 (0.41–1.99) 3.02 (0.99–9.18) 1.05 (0.28–3.90) 1.44 (0.08–25.01)
2.74 (1.02–7.37)* 1.38 (0.49–3.93) 6.06 (1.60–22.97)* 2.69 (0.64–11.30) 2.56 (0.09–74.30)
MED dose at discharge was calculated as morphine equivalent does. p <0.05.
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Table 4 – The odds ratio and 95% confidence intervals of drug and alcohol use as a predicting factor for being on opioids at a specific clinic visit. History of drug abuse History of alcohol abuse aOR (95% CI) aOR (95% CI) 14 Days 30 Days 60 Days 90 Days 365 Days *
2.86 0.75 1.11 7.67 4.97
(0.69–11.88) (0.22–2.59) (0.22–5.47) (1.67–35.26)* (0.17–145.13)
1.23 (0.45–3.35) 3.14 (1.25–7.93)* 5.92 (1.81–19.36)* 2.89 (0.80–10.42) 12.46 (0.72–215.00)
p <0.05.
point was there a statistical significance. For patients with preinjury alcohol abuse at 30 days there was an increased risk of being on opioids (OR 3.14; CI 1.25–7.93). This risk continued at 60 days (OR 5.92; CI 1.81–19.36), but then was not significant thereafter.
4.
Discussion
The purpose of this study was to characterize the outpatient opioid use of burn patients as well as predictive factors for long term use. Practitioners have become more cognizant of prescription patterns as opioid abuse has increased. At the same time, state and federal governments have also increased pressure on doctors to decrease the amounts of opioid prescribed. For instance, The State of Washington Medicaid Program has restricted the prescribing practices of clinicians limiting the total daily MED amount to 90 with specific exemptions [5]. The State recommends prescribing medication for a total of only 7 days and patients requesting opioid pain medication longer than three months to be assessed by a pain management specialist [6]. According to the Center for Disease Control, doses above 50 MED are considered high [7]. These stricter criteria present a challenge for burn pain management as these levels are often exceeded in order to control pain. From our data, many patients who received high doses of opioids would be off them by 14 days but are incorrectly categorized as “high risk” by the new state and federal definitions. Opioids will continue to be the main class of medication for post-discharge pain management for burn survivors due to the effectiveness and versatility [8]. Different routes and half-lives allow for medications which are useful for background pain, procedural pain, and breakthrough pain in both sedated and awake patients [9]. Another benefit of adequate pain control is improved outcomes decreasing morbidity of patients after discharge. When patients have better pain control they have less incidence of post-traumatic stress disorder and better functional outcomes [10]. Pain treatment is necessary even after a patient’s wounds have “healed,” and still remains an important part of burn care. A vast majority of patients were still prescribed opioid pain medication at the day of discharge but tapered off of use by 90 days. Interestingly, those patients who were on opioids at 90 days were more likely to be on them at one year. This is similar to a study from Salas et al. which looked at a general
cohort of patients and tracked opioid use. Patients who were prescribed opioids at 90 days in this study also had a high risk of being on opioids long term [11]. Even if burns are healed and grafted they are still painful. Months after injury, patients complain of significant neuropathic pain, itch, and a generalized ache. In a study by Choinière et al. 82% of patients experiences neuropathic pain at one year and 35% complained of pain in the scarred tissue [12]. Browne et al. showed that patients with higher pain medication utilisation in an outpatient setting also had higher rates of depression and anxiety [13]. In a survey of burn survivors by Dauber et al., chronic outpatient pain interfered with daily living 55% of the time. Clearly, pain management still is a tremendous problem for outpatient burn care months after injury. Burn providers must now focus on different treatment modalities, both pharmacological and nonpharmacological for adequate outpatient pain control. Approximately 10% of patients will remain on opioids at one year. Other studies which involve non-burn patients have demonstrated similar levels suggesting that even though burn patients received higher initial doses long term risk may not be elevated [14]. When examining the data for predictive factors for chronic use little of the data was significant. Patients who were on medium and high doses of opioids were more likely to be on opioids at two weeks, but this was not surprising as patients are usually weaned down at a steady rate to prevent withdrawal. The higher MED group still had a statistically significant chance of being on opioids at day 60 but not significant after that. Even with high doses at day of discharge patients managed to wean off of these medications quickly and did not become chronic users. There continued to be a large percentage of patients in the Low MED group who were on opioid medications at day 365 but did not find any statistically significant risks factors associated with this group. Other factors examined also did little to impact opioid use. When examining age or sex, there was no significance for use of medications. Other studies have also shown no clinical significance. Thielke et al. examined two large American health systems and found no predictive factors for chronic opioid use based off of age or sex [15]. Malenfant et al. examined long term chronic sensory problems in burn patients and found no difference in either of these two demographic variables or in TBSA burned areas either [16]. Data on TBSA grafted is limited on whether patients used more opioids long term. This variable, as well as total TBSA burn size was used as a marker for the severity of the burn. One reason these patients might not have been on opioids long term in an outpatient setting is that these patients may have stayed in the hospital for a longer duration and begun their opioid tapers in house. Previous history of drug and alcohol abuse is a known risk factor for opioid misuse [17]. In our study, patients who endorsed a history of drug abuse were more likely to be on opioids at day 90 but this was not significant for other time points. Alcohol was also predictive at 30 and 60 days but again was not significant after. Sullivan et al. when studying commercial and Medicaid insurance plans did find a positive correlation of opioid abuse and substance dependence [18]. This conflicting data demonstrates one of the limitations of our study. Drug and alcohol dependence was based off of selfreported questionnaires and patients may have decided to not
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answer truthfully. Another issue is our study focused on prescribed and recorded opioid use by patients. Those who were obtaining multiple prescriptions from outside sources or through illegal means would have unreported usage of opioids. Another limitation in our study was the lack of standardization in weaning regimens or type of medications used in our patient population. This made it difficult to standardize patient’s pain medication use and weaning plans. Our center is fairly homogenous in opioid prescribing and will only give medications if a patient complains of significant pain that is altering his/her daily living or uses pain medication for daily wound care. Over the 10-year period of the study, practices in opioid prescriptions may have changed which was not effectively captured in the cohort. For example, there has been a growing emphasis on multimodal therapy with other classes of medications such as gabapentin, acetaminophen, and NSAIDs. For instance, if a patient complains of neuropathic pain or itch, gabapentin is now routinely prescribed as a first line treatment. These adjunct medications may affect the use and amount of opioid medications. The lack of standardization is not limited to our burn center but there is significant practice variability nationally and internationally on the treatment of outpatient pain regimens [19]. A standardization would enable all patients to be on the same algorithm and help to spot those patients who are still using opioid pain medications long term.
5.
Conclusion
Clearly there is a patient population of around 10% who become chronic users which we found in our patient population as well as validated in other studies including other burn cohorts [20]. The predisposing factors of who is at risk for long term risk is difficult to ascertain. Age, sex, and amount of opioids used at discharge did not affect long term use. Previous drug and alcohol use also did not affect patients after 90 days. Clearly new screening tools have to be developed to better identify these patients early [21]. Through this, patients predisposed to opioid dependence and abuse can receive earlier interventions to prevent long term use and overall use of an effective but dangerous medication can be reduced.
Authors roles and preparation of this manuscript All listed authors have provided (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; (3) final approval of the version to be published; (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Statement of institutional review board The following study has been approved by the University of Washington Institutional Review Board (IRB).
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Conflict of interest There are no conflicts of interest for any authors.
Funding The contents of this manuscript were developed under a grant from the National Institute on Disability and Rehabilitation Research (NIDILRR grant #90DP0029). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this manuscript do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. REFERENCES
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