Trends in opioid use before critical illness among elderly patients in Ontario
CCCF ePoster library. Wang H. 11/12/19; 285174; EP81
Dr. Han Ting Wang
Dr. Han Ting Wang
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Topic: Retrospective or Prospective Cohort Study or Case Series

Wang, Han Ting, MD MSc1; Hill, Andrea PhD2,3; Gomes, Tara MHSc, PhD4,5,6; Pinto, Ruxandra, PhD3; Wijeysundera, Duminda, MD PhD4,6,7,8; Scales, Damon C., MD, PhD2,3,6,9,10, Fowler, Robert, MDCDM MS(Epi)2,3,6,9,10; Wunsch, Hannah MD MSc2,3,6,7,10

  1. Critical care division, Department of Medicine, Maisonneuve-Rosemont Hospital affiliated with the University of Montreal, Montreal, QC, Canada
  2. Sunnybrook Research Institute, Toronto, ON, Canada
  3. Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
  4. Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
  5. Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
  6. Institute of Clinical Evaluative Sciences, Toronto, ON, Canada
  7. Department of Anesthesia, University of Toronto, Toronto, ON, Canada
  8. Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
  9. Department of Medicine, University of Toronto, Toronto, ON, Canada
  10. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

Introduction: Opioid consumption in some developed countries has risen to epidemic proportions (1). It is also associated with increased risk of cardiovascular events and death especially in the elderly population (2, 3). The prevalence of prior opioid exposure among patients admitted intensive care units (ICU) and its impact on outcomes remain unknown.
Objectives: To assess temporal trends in pre-existing opioid exposure prior to hospitalization among elderly patients with critical illness and to determine whether prior opioid exposure is associated with adverse outcomes during hospitalization.
Methods: We performed a population-based cohort study using health administrative datasets from Ontario, Canada. We included all hospitalizations among Ontario residents aged > 65 years that involved an ICU admission between 2002 and 2014. The exposure was opioid use before admission, categorized as chronic use, intermittent use, and non-use. Chronic use is defined as having filled at least one opioid prescription with a duration overlapping the day of hospital admission and to have filled at least 10 opioid prescriptions and/or any number of opioid prescriptions having at least 120 cumulative days of supply during the 1-year look-back period. Intermittent use is defined as having filled at least one opioid prescription in the year before hospitalization but not meeting criteria for chronic use. Non-use is defined as not filling any opioid prescriptions in the year prior to hospitalization.
The primary outcome was hospital mortality. The association between opioid exposure and hospital mortality was assessed using generalized estimating equations. A secondary outcome was time to hospital discharge, evaluated using Fine and Gray regression model, accounting for the competing risk of death.
The cohort included 711,312 elderly patient admissions to an ICU during the study period. Of these admissions, 6.8% (n=48,363) were chronic opioid users, 28.1% (n=200,149) intermittent users, and 65.0% (n=462,800) non-users. The prevalence of chronic users increased from 5.3% (95% CI, 5.1%-5.5%) in 2002 to 8.1% (95% CI, 7.9%-8.3%; p-value for trend <0.0001) in 2014 (figure 1). Compared with non-users, chronic opioid users and intermittent users had higher in-hospital mortality (adjusted odds ratio: 1.12, 95% CI, 1.09-1.15, p<0.0001 for chronic users; adjusted odds ratio: 1.09, 95% CI, 1.07-1.11, p<0.0001 for intermittent users), and a lower subdistribution hazard of time to hospital discharge, translating to a longer hospital length of stay (adjusted subdistribution hazard ratio: 0.87, 95% CI, 0.85-0.88, p<0.0001 for chronic users; 0.93, 95% CI, 0.92-0.94, p<0.0001 for intermittent users) (table 1).
Conclusion: The prevalence of chronic opioid use has increased among elderly patients who required ICU admission and is associated with worse hospital outcomes. While prior opioid use may not be easily modifiable, future studies should explore in-hospital and in-ICU interventions that can decrease opioid use in these chronic users, and to evaluate the impact of chronic use on subsequent clinical outcomes.

  1. Fischer B, Keates A, Buhringer G, Reimer J, Rehm J: Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction 2014; 109(2):177-181.
  2. Baldini A, Von Korff M, Lin EHB: A Review of Potential Adverse Effects of Long-Term Opioid Therapy: A Practitioner's Guide. The Primary Care Companion to CNS Disorders 2012; 14(3):PCC.11m01326.
  3. Solomon DH, Rassen JA, Glynn RJ, et al: The comparative safety of opioids for nonmalignant pain in older adults. Archives of internal medicine 2010; 170(22):1979-1986.
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