Multimodal Analgesic Prescribing in U.S. Adults After an ICU Hospitalization for Major Surgery

Introduction: SCCM PADIS guidelines recommend use of non-opioid analgesics after major surgery requiring an ICU admission to reduce opioid consumption. However, the current U.S. use of partial opioid agonists (POA) and non-opioid analgesics after an ICU hospitalization for major surgery, and the factors associated with this use, remain unclear.


Methods: Using the U.S. IQVIA PharMetrics Plus claims database, we identified adults who underwent major surgery, were admitted to an ICU, and discharged from hospital to home with insurance coverage ≥30 days. We excluded patients prescribed a full opioid agonist (FOA), a POA, or a non-opioid analgesic, diagnosed with OUD or admitted to an ICU in the 6 months prior to the surgical ICU hospitalization. We collected data on age, sex, surgical site, comorbidity(CCI), frailty(HFRS) and all FOA, POA (e.g., tramadol) and non-opioid analgesic [i.e., acetaminophen, anticonvulsants (gabapentin, pregabalin), lidocaine patch, NSAIDS, and tricyclic antidepressants (TCAs)] prescriptions in the two months after the surgical ICU hospitalization and conducted a 6-variable regression analysis to identify factors associated with post-hospitalization POA and non-opioid analgesic use.


Results: Among 12,109 patients included, 5850 (48.3%) were excluded. A total of 768 (12.3%) of the 6259 patients [age 72(65,79), CCI 4(2,7), cardiac surgery 55%], were prescribed ≥1 POA or non-opioid analgesic in the 2-months after hospitalization [POA 342/768 (44.5%), anticonvulsant 293/768 (38.2%), acetaminophen 159/768 (20.7%), NSAID 139/768 (18.1%), TCA 6/768 (0.8%), lidocaine 0%)] and 5,491 (87.7%) were not. Most patients were prescribed only 1 POA/non-opioid analgesic (621/768, 80.9%). Among the 1409/6259 (22.5%) patients newly prescribed a FOA (vs. the pre-ICU hospitalization period), only 340/1409 (22.5%) were concomitantly prescribed a POA or non-opioid analgesic. Thoracic surgery (aOR=1.99, 95%CI 1.4,2.8) and newly prescribed FOA therapy (aOR=2.11, 95%CI 1.8, 2.5) were each independently associated with greater post-hospitalization POA/non-opioid analgesic prescribing.


Conclusions: U.S. adults undergoing major surgery requiring an ICU admission are infrequently prescribed partial opioid analgesics or non-opioid analgesics after hospital discharge, even when full opioid agonists are prescribed.