Comorbid Insomnia and Sleep Apnea are
Associated with Greater Downstream Health
Care Utilization and Chronic Opioid Use after
Arthroscopic Hip Surgery
Authors: Rhon Daniel I. 
Published: February 2021

Background: There is a relationship between sleep, pain, and chronic opioid utilization. This
has been poorly explored in general, and especially in patients undergoing orthopaedic surgery.
Fewer studies have investigated this relationship based on a sleep diagnosis present both before
and after surgery.
Objectives: To identify the association between insomnia and sleep apnea and downstream
opioid use and medical utilization (visits and cost) in the 2 years following arthroscopic hip surgery.
Study Design: A retrospective cohort.
Setting: The US Military Health System.
Methods: This was a consecutive cohort of individuals undergoing hip arthroscopy in the Military
Health System (MHS). Medical utilization data were abstracted from the MHS Data Repository
between 2003 and 2015, representing 1 year prior and 2 years after surgery for every individual.
Sleep disorder diagnoses (insomnia and sleep apnea) were identified using International Classification
of Disease codes, and opioid utilization was determined from pharmacy data based on American
Hospital Formulary Service codes 280808 and 280812. Sleep disorders present before surgery were
used as predictors in multivariate logistic regression, and sleep disorders present after surgery were
examined for associations with the outcomes using the Chi-square tests. The dependent variables in
both cases were downstream medical utilization (costs, visits, and opioid use).
Results: Of 1870 eligible patients (mean age 32.3 years; 44.5% women), 165 (8.8%) had a diagnosis
of insomnia before surgery and 333 (17.8%) after surgery; whereas 93 (5.0%) had a diagnosis of apnea
before surgery and 268 (14.3%) after surgery. A diagnosis of insomnia before surgery predicted having
at least 3+ opioids prescriptions after surgery (adjusted odds ratio, 1.97 [95% confidence interval, 1.39,
2.79]) and greater downstream total medical visits and costs in the 2 years after surgery. However, the
number of individuals with a diagnosis of insomnia or apnea after surgery more than doubled, and
was significantly associated with chronic opioid use, all-cause medical and all hip-related medical
downstream visits and costs in the 2 years after surgery.
Limitations: The use of observational data and claims data are only as good as how it was entered.
Conclusions: Sleep disorders prior to surgery predicted chronic opioid use and medical utilization
after surgery. However, a much higher rate of individuals had sleep apnea and insomnia present
after surgery, which were significantly associated with chronic opioid use and greater total and
hip-related medical utilization (visits and costs). Screening for sleep disorders prior to surgery may
be important, but an even higher rate of sleep disorders may be developed after surgery, and
continued screening after surgery may have greater clinical merit. Assessing quality of sleep during
perioperative management may provide a unique opportunity to decrease pain and chronic opioid
use after surgery.
Key words: Pain, opioid use, insomnia, sleep apnea, orthopaedic surgery, military medicine,
health care utilization
Pain Physician 2019