Association between opioid and benzodiazepine use and clinical deterioration in ward patients
BACKGROUND
Opioids and benzodiazepines are frequently used in hospitals, but little is known about outcomes among ward patients receiving these medications.
OBJECTIVE
To determine the association between opioid and benzodiazepine administration and clinical deterioration.
DESIGN
Observational cohort study.
SETTING
500-bed academic urban tertiary-care hospital.
PATIENTS
All adults hospitalized on the wards from November 2008 to January 2016 were included. Patients who were “comfort care” status, had tracheostomies, sickle-cell disease, and patients at risk for alcohol withdrawal or seizures were excluded.
MEASUREMENTS
The primary outcome was the composite of intensive care unit transfer or ward cardiac arrest. Discrete-time survival analysis was used to calculate the odds of this outcome during exposed time periods compared to unexposed time periods with respect to the medications of interest, with adjustment for patient demographics, comorbidities, severity of illness, and pain score.
RESULTS
In total, 120,518 admissions from 67,097 patients were included, with 67% of admissions involving opioids, and 21% involving benzodiazepines. After adjustment, each equivalent of 15 mg oral morphine was associated with a 1.9% increase in the odds of the primary outcome within 6 hours (odds ratio [OR], 1.019; 95% confidence interval [CI], 1.013-1.026; P < 0.001), and each 1 mg oral lorazepam equivalent was associated with a 29% increase in the odds of the composite outcome within 6 hours (OR, 1.29; CI, 1.16-1.45; P < 0.001).
CONCLUSION
Among ward patients, opioids were associated with increased risk for clinical deterioration in the 6 hours after administration. Benzodiazepines were associated with even higher risk. These results have implications for ward-monitoring strategies. Journal of Hospital Medicine 2017;12:428-434. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
CONCLUSION
After adjustment for important confounders including severity of illness, medication dose, and time, opioids were associated with a slight increase in clinical deterioration on the wards, while benzodiazepines were associated with a much larger risk for deterioration. This finding raises concern about the safety of benzodiazepine use among ward patients and suggests that increased monitoring of patients receiving these medications may be warranted.
Acknowledgment
The authors thank Nicole Twu for administrative support.
Disclosure
Drs. Churpek and Edelson have a patent pending (ARCD. P0535US.P2) for risk stratification algorithms for hospitalized patients. Dr. Churpek is supported by a career development award from the National Heart, Lung, and Blood Institute (K08 HL121080). Dr. Churpek has received honoraria from Chest for invited speaking engagements. In addition, Dr. Edelson has received research support from Philips Healthcare (Andover, Massachusetts), research support from the American Heart Association (Dallas, Texas) and Laerdal Medical (Stavanger, Norway), and research support from Early Sense (Tel Aviv, Israel). She has ownership interest in Quant HC (Chicago, Illinois), which is developing products for risk stratification of hospitalized patients. Dr. Mokhlesi is supported by National Institutes of Health grant R01HL119161. Dr. Mokhlesi has served as a consultant to Philips/Respironics and has received research support from Philips/Respironics. Preliminary versions of these data were presented as a poster presentation at the 2016 meeting of the American Thoracic Society, May 17, 2016; San Francisco, California.
