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Association Between Opioid Administration During Mechanical Ventilation and Subsequent Opioid Use

Sunday, January 21, 2024
11:00 AM – 11:10 AM MT
Location: Connections Central - Star Research Theater
Introduction: An analgesia-first sedation strategy during mechanical ventilation (MV) is a guideline-based intensive care unit (ICU) practice, resulting in many critically ill patients receiving opioids. Healthcare opioid exposure in non-ICU settings is associated with subsequent outpatient opioid use, but the long-term impact of opioid administration during MV is uncharacterized. We hypothesized that higher opioid doses during MV would result in increased opioid use after hospital discharge.


Methods: Our retrospective cohort study included adult patients in 21 Kaiser Permanente Northern California medical ICUs (2012-2019) who received MV ≥24 hours for acute respiratory failure, survived to discharge, and did not have prior comfort-focused care/hospice referral. The primary exposure was tercile of median daily fentanyl equivalents (MDFE) administered during the first 21 MV days. Patients who did not receive opioids were the reference group. The primary outcome was a filled opioid prescription (Rx) in the year after discharge modeled using a time to event analysis with death as a competing risk. Secondary outcomes included 1) an opioid Rx filled in 30 days, 2) an opioid Rx filled in 1 year and 3) persistent opioid use over 1 year, all modeled as binary outcomes using logistic regression. Models were adjusted for patient demographics; social determinants of health; Charlson comorbidities; opioid Rx, chronic pain, or opioid-related diagnoses in the prior year; principal diagnosis; length of stay; and code status.


Results: We included 6,746 patients; 2,942 (43.6%) experienced the primary outcome. The MDFE distribution was a median 200µcg (Interquartile range 40µcg, 1000µcg) with Tercile 1 0-67µcg, Tercile 2 >67-700µcg and Tercile 3 >700µcg. Compared to patients who received no opioid, higher MDFE was associated with more opioid Rxs in the year after discharge: Tercile 1 Hazard Ratio (HR) 1.01 (95% Confidence Interval 0.87-1.18), Tercile 2 HR 1.23 (1.06-1.43), Tercile 3 HR 1.31 (1.13-1.53). Results were similar for secondary outcomes.


Conclusions: Administering higher opioid doses during MV is associated with increased post-discharge opioid use, including persistent use. Given the harms of the ongoing opioid epidemic, future studies should evaluate the risks and benefits of opioid-sparing strategies during MV.