Multimorbidity and Opioid Prescribing in Hospitalized Older Adults

Abstract

Background: Multimorbidity and pain are both common among older adults, yet pain treatment strategies for older patients with multimorbidity have not been well characterized. Objectives: To assess the prevalence and relationship between multimorbidity and opioid prescribing in hospitalized older medical patients with pain. Methods: We collected demographic, morbidity, pain, and analgesic treatment data through structured review of the electronic medical records of a consecutive sample of 238 medical patients, aged ‡65 years admitted between November 2014 and May 2015 with moderate-to-severe pain by numerical pain rating scale (range 4-10). We used the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) to assess multimorbidity and cumulative illness burden. We examined the relationship between morbidity measures and opioid prescribing at hospital discharge using multivariate regression analysis. Results: The mean age was 75 -8 years, 57% were female and 50% were non-White. Mean CIRS-G total score was 17 -6, indicating high cumulative illness burden. Ninety-nine percent of patients had multimorbidity, defined as moderate-to-extremely severe morbidity in ‡2 organ systems. Sixty percent of patients received an opioid prescription at discharge. In multivariate analyses adjusted for age, race, and gender, patients with a discharge opioid prescription were significantly more likely to have higher cumulative illness burden and chronic pain. Conclusion: Among older medical inpatients, multimorbidity was nearly universal, and patients with higher cumulative illness burden were more likely to receive a discharge opioid prescription. More studies of benefits and harms of analgesic treatments in older adults with multimorbidity are needed to guide clinical practice.

The patterns and burden of multimorbidity in geriatric patients with prolonged use of addictive medications

“…Research in Iceland showed that the majority of those who received benzodiazepine and/or Z-hypnotic prescriptions were multimorbid; and that those with multimorbidity were 15 times more likely than those without to be prescribed these drugs [ 24 ]. Another recent study focussing on older hospitalized patients in San Francisco, also reported that patients with higher multimorbidity burden tended to receive prescriptions of opioid analgesics at discharge, adjusted for sociodemographic variables, and pain [ 15 ]. Our results corroborate these findings, and also suggest that multimorbidity is not only associated with prescribing but also with long-term use of addictive medications.…”

“…Very few studies have examined this topic specifically among older patients. Also, those conducted generally aimed to assess the likelihood of being prescribed potentially addictive medications rather than the effect of multimorbidity on prolonged drug use [ 15 , 16 ]. Moreover, insights regarding diseases that commonly coexist with prolonged use are scarce.…”

Opioid prescribing on discharge to skilled nursing facilities

“…Our observation that more than 70% of discharges to a SNF were prescribed an opioid is higher than has been described in previous studies. Schear et al reported that 60% of patients in a sample of older adults with moderate to severe pain were prescribed an opioid on discharge 21 . In another study, Calceterra et al used a retrospective cohort study of opioid naive patients to quantify the frequency of opioid prescribing on discharge from a large safety‐net hospital and observed that 25% of patients received an opioid within 72 hours of hospital discharge 22 .…”

“…Schear et al reported that 60% of patients in a sample of older adults with moderate to severe pain were prescribed an opioid on discharge. 21 In another study, Calceterra et al used a retrospective cohort study of opioid naive patients to quantify the frequency of opioid prescribing on discharge from a large safety-net hospital and observed that 25% of patients received an opioid within 72 hours of hospital discharge. 22 However, both of these studies included patients discharged to all locations compared to our study which focused on patients discharged to a SNF.…”

“…Our observation that patients with a diagnosis of chronic pain were significantly more likely to be prescribed an opioid is consistent with previous studies. 3,21,30 Approximately 46% of patients prescribed on opioid on discharge had a diagnosis of chronic pain compared to 20% that did not have this diagnosis. Chronic pain is prevalent in SNFs, however previous studies also report that SNF residents are often undertreated for pain.…”