Sleep Apnea, Insomnia Linked With Higher Postoperative Opioid Use, Care Utilization

In individuals undergoing hip arthroscopy in the Military Health System, a diagnosis of sleep apnea or insomnia after the surgery was associated with chronic opioid use, more healthcare visits, and higher medical costs.

The investigators, who published their findings in Pain Physician, described research on the topic as “crucial and timely” because military service members are known to have a higher prevalence of sleep disorders, chronic pain, and chronic opioid use. They studied a retrospective cohort of patients aged 18 to 50 years who underwent arthroscopic hip surgery between June 30, 2004, and July 1, 2013, in the Military Health System’s data repository. Patients in this repository were beneficiaries of TRICARE, the military health insurance program, and could include active-duty or retired service members, as well as their family members.

Of the 1870 individuals identified, the mean age was 32.3 years, 55.5% were men, and 76.3% were from a lower socioeconomic status, which was measured by military rank. In that cohort, 165 (8.8%) had a diagnosis of insomnia and 93 (5%) had a diagnosis of apnea in the 12 months before surgery; the 93 with apnea included 29 individuals who also had insomnia before the surgery.

After surgery, the numbers of patients with either diagnosis more than doubled: Insomnia was diagnosed in 333 patients (17.8%) and apnea in 268 (14.3%). The presence of either insomnia or apnea after surgery was significantly associated with having more total and hip-related healthcare visits, higher total and hip-related healthcare costs, and a higher likelihood of having 3 or more opioid prescriptions within 2 years after surgery.

For instance, postoperative insomnia and apnea were associated with 154% and 64% greater odds, respectively, of having 3 or more opioid prescriptions within 2 years (P <.01 for both). Those with insomnia after surgery were also more likely to be still taking opioids at 1 year after surgery (odds ratio, 2.50; 95% CI, 1.90-3.28; P <.01).

Because patients were likely to have pain before and after the surgery, and because of the bidirectional relationship between disordered sleep and pain, the investigators were not surprised to find that rates of insomnia and sleep apnea were high in both periods. Complications from the surgery may have adversely affected sleep for some patients, leading to the increase in diagnoses seen after the operation.

The findings “suggest that screening for sleep disorders prior to surgery may not be enough and may need to continue after surgery, in which the diagnosis may become more prevalent,” the study authors wrote. They also recommended implementing sleep disorder screening and intervention processes before and after surgery. With greater care coordination, sleep specialists could be part of the integrated care team for patients undergoing orthopedic surgery.

Further research could look at how more effective pain management can improve the quality of sleep, or vice versa, the study authors wrote. They also suggested that research teams could assess the effects of adding information on the relationship among pain, sleep, and opioids to the surgical consent process.

“These results suggest that identifying the presence of insomnia prior to hip surgery may have value, but perhaps more impactful is the screening for sleep disorders that may occur after surgery,” they concluded. “Assessing and addressing quality of sleep as part of the perioperative management for patients, both before and after hip surgery, may be one approach to helping decrease pain and chronic opioid use after surgery.”

Reference

Rhon DI, Snodgrass SJ, Cleland JA, Cook CE. Comorbid insomnia and sleep apnea are associated with greater downstream health care utilization and chronic opioid use after arthroscopic hip surgery. Pain Physician. 2019;22(4):E351-E360.