---
title: "Initial opioid selection for continuous infusions in mechanically ventilated ICU patients: trends"
id: "pubmed-42681402"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42681402"
content_type: "clinical_feed_article"
specialty: "Critical Care"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42681402/"
doi: "10.1007/s12630-026-03173-9"
published_at: "2026-09-02T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Initial opioid selection for continuous infusions in mechanically ventilated ICU patients: trends
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42681402
- **Specialty:** [Critical Care](https://medichelpline.com/clinical-feed/critical-care.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42681402/)
- **DOI:** [10.1007/s12630-026-03173-9](https://doi.org/10.1007%2Fs12630-026-03173-9)
- **Published At:** 2026-09-02T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- This retrospective cohort study described choices of **initial opioid** continuous infusions in adult ICU patients receiving **mechanical ventilation** across 20 ICUs in Alberta, Canada, from 2013–2019. - The cohort included 17,898 ICU admissions in which the first continuous opioid infusion was fentanyl, hydromorphone, or morphine. - **Fentanyl** was the predominant initial opioid (78.6%; n = 14,060), followed by **hydromorphone** (16.3%; n = 2,917) and **morphine** (5.1%; n = 921). - Temporal trends showed decreasing use of fentanyl (from 89.0% in 2013 to 75.0% in 2019) and morphine (from 7.7% to 3.2%), while hydromorphone use increased (from 3.3% to 21.8%); P < 0.001 for trends. - In multilevel multinomial logistic regression, surgical patients had higher adjusted odds of receiving hydromorphone versus fentanyl (aOR 1.52; 95% CI 1.32–1.74) and lower adjusted odds of receiving morphine versus fentanyl (aOR 0.81; 95% CI 0.68–0.96). - There was marked **inter-ICU variability** in initial opioid choice: adjusted median odds ratio (aMOR) for hydromorphone versus fentanyl was 14.5 (95% CI 7.3–25.7) and for morphine versus fentanyl was 5.2 (95% CI 3.11–9.2). - Authors conclude that opioid-prescribing practices changed over time and varied substantially across ICUs; they recommend further research to understand drivers of variability and to evaluate associations between opioid selection and clinical outcomes to inform guidelines.
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Online ahead of print. # Choice of initial opioid for continuous infusions in patients receiving mechanical ventilation: a retrospective cohort study [Rebecca Piland](https://pubmed.ncbi.nlm.nih.gov/?term=Piland+R&cauthor_id=42681402)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-1 "Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA."), [Andrea D Hill](https://pubmed.ncbi.nlm.nih.gov/?term=Hill+AD&cauthor_id=42681402)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-2 "Sunnybrook Research Institute, Toronto, ON, Canada."), [Lisa Burry](https://pubmed.ncbi.nlm.nih.gov/?term=Burry+L&cauthor_id=42681402)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-3 "Departments of Pharmacy and Medicine, Sinai Health, Toronto, ON, Canada.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-4 "Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada."), [David N Juurlink](https://pubmed.ncbi.nlm.nih.gov/?term=Juurlink+DN&cauthor_id=42681402)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-2 "Sunnybrook Research Institute, Toronto, ON, Canada.")[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-5 "Departments of Medicine, Pediatrics, and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada."), [Nicholas A Bosch](https://pubmed.ncbi.nlm.nih.gov/?term=Bosch+NA&cauthor_id=42681402)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-6 "Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA."), [Bijan Teja](https://pubmed.ncbi.nlm.nih.gov/?term=Teja+B&cauthor_id=42681402)[ 7 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-7 "Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada.")[ 8 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-8 "Department of Anesthesiology, St. Michael's Hospital, Toronto, ON, Canada."), [Henry T Stelfox](https://pubmed.ncbi.nlm.nih.gov/?term=Stelfox+HT&cauthor_id=42681402)[ 9 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-9 "Departments of Critical Care Medicine, University of Alberta and University of Calgary, Calgary, AB, Canada."), [Theodore J Iwashyna](https://pubmed.ncbi.nlm.nih.gov/?term=Iwashyna+TJ&cauthor_id=42681402)[ 10 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-10 "Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA.")[ 11 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-11 "School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA."), [Allan Walkey](https://pubmed.ncbi.nlm.nih.gov/?term=Walkey+A&cauthor_id=42681402)[ 12 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-12 "Department of Medicine, UMass Chan Medical School, Worcester, MA, USA."), [Hannah Wunsch](https://pubmed.ncbi.nlm.nih.gov/?term=Wunsch+H&cauthor_id=42681402)[ 13 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-13 "Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA. haw9006@med.cornell.edu.")[ 14 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-14 "Sunnybrook Research Institute, Toronto, ON, Canada. haw9006@med.cornell.edu.")[ 15 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#full-view-affiliation-15 "Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada. haw9006@med.cornell.edu.") Affiliations Expand ### Affiliations * 1 Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA. * 2 Sunnybrook Research Institute, Toronto, ON, Canada. * 3 Departments of Pharmacy and Medicine, Sinai Health, Toronto, ON, Canada. * 4 Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. * 5 Departments of Medicine, Pediatrics, and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. * 6 Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA. * 7 Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada. * 8 Department of Anesthesiology, St. Michael's Hospital, Toronto, ON, Canada. * 9 Departments of Critical Care Medicine, University of Alberta and University of Calgary, Calgary, AB, Canada. * 10 Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA. * 11 School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. * 12 Department of Medicine, UMass Chan Medical School, Worcester, MA, USA. * 13 Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA. haw9006@med.cornell.edu. * 14 Sunnybrook Research Institute, Toronto, ON, Canada. haw9006@med.cornell.edu. * 15 Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada. haw9006@med.cornell.edu. * PMID: **42681402** * DOI: [ 10.1007/s12630-026-03173-9 ](https://doi.org/10.1007/s12630-026-03173-9) Item in Clipboard # Choice of initial opioid for continuous infusions in patients receiving mechanical ventilation: a retrospective cohort study Rebecca Piland et al. Can J Anaesth. 2026. Show details Display options Display options Format Abstract PubMed PMID Can J Anaesth Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Can+J+Anaesth%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Can+J+Anaesth%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42681402/) . 2026 Sep 2. doi: 10.1007/s12630-026-03173-9. Online ahead of print. ### Authors [Rebecca Piland](https://pubmed.ncbi.nlm.nih.gov/?term=Piland+R&cauthor_id=42681402)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-1 "Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA."), [Andrea D Hill](https://pubmed.ncbi.nlm.nih.gov/?term=Hill+AD&cauthor_id=42681402)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-2 "Sunnybrook Research Institute, Toronto, ON, Canada."), [Lisa Burry](https://pubmed.ncbi.nlm.nih.gov/?term=Burry+L&cauthor_id=42681402)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-3 "Departments of Pharmacy and Medicine, Sinai Health, Toronto, ON, Canada.")[ 4 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-4 "Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada."), [David N Juurlink](https://pubmed.ncbi.nlm.nih.gov/?term=Juurlink+DN&cauthor_id=42681402)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-2 "Sunnybrook Research Institute, Toronto, ON, Canada.")[ 5 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-5 "Departments of Medicine, Pediatrics, and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada."), [Nicholas A Bosch](https://pubmed.ncbi.nlm.nih.gov/?term=Bosch+NA&cauthor_id=42681402)[ 6 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-6 "Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA."), [Bijan Teja](https://pubmed.ncbi.nlm.nih.gov/?term=Teja+B&cauthor_id=42681402)[ 7 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-7 "Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada.")[ 8 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-8 "Department of Anesthesiology, St. Michael's Hospital, Toronto, ON, Canada."), [Henry T Stelfox](https://pubmed.ncbi.nlm.nih.gov/?term=Stelfox+HT&cauthor_id=42681402)[ 9 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-9 "Departments of Critical Care Medicine, University of Alberta and University of Calgary, Calgary, AB, Canada."), [Theodore J Iwashyna](https://pubmed.ncbi.nlm.nih.gov/?term=Iwashyna+TJ&cauthor_id=42681402)[ 10 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-10 "Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA.")[ 11 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-11 "School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA."), [Allan Walkey](https://pubmed.ncbi.nlm.nih.gov/?term=Walkey+A&cauthor_id=42681402)[ 12 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-12 "Department of Medicine, UMass Chan Medical School, Worcester, MA, USA."), [Hannah Wunsch](https://pubmed.ncbi.nlm.nih.gov/?term=Wunsch+H&cauthor_id=42681402)[ 13 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-13 "Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA. haw9006@med.cornell.edu.")[ 14 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-14 "Sunnybrook Research Institute, Toronto, ON, Canada. haw9006@med.cornell.edu.")[ 15 ](https://pubmed.ncbi.nlm.nih.gov/42681402/#short-view-affiliation-15 "Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada. haw9006@med.cornell.edu.") ### Affiliations * 1 Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA. * 2 Sunnybrook Research Institute, Toronto, ON, Canada. * 3 Departments of Pharmacy and Medicine, Sinai Health, Toronto, ON, Canada. * 4 Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. * 5 Departments of Medicine, Pediatrics, and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. * 6 Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA. * 7 Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada. * 8 Department of Anesthesiology, St. Michael's Hospital, Toronto, ON, Canada. * 9 Departments of Critical Care Medicine, University of Alberta and University of Calgary, Calgary, AB, Canada. * 10 Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA. * 11 School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. * 12 Department of Medicine, UMass Chan Medical School, Worcester, MA, USA. * 13 Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA. haw9006@med.cornell.edu. * 14 Sunnybrook Research Institute, Toronto, ON, Canada. haw9006@med.cornell.edu. * 15 Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada. haw9006@med.cornell.edu. * PMID: **42681402** * DOI: [ 10.1007/s12630-026-03173-9 ](https://doi.org/10.1007/s12630-026-03173-9) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID ## Abstract in [ English, ](https://pubmed.ncbi.nlm.nih.gov/42681402/#eng-abstract) [ French ](https://pubmed.ncbi.nlm.nih.gov/42681402/#fra-abstract) **Purpose:** Limited evidence exists to inform opioid selection in patients in the intensive care unit (ICU) receiving mechanical ventilation, and current guidelines treat opioids as interchangeable. We sought to describe temporal trends in, and factors associated with, the choice of first opioid infusion in critically ill patients. **Methods:** We conducted a historical cohort study of patients receiving mechanical ventilation (MV) in ICUs in Alberta, Canada, 2013-2019. We included patients who received a first continuous infusion of fentanyl, hydromorphone, or morphine. We assessed temporal trends and used a multilevel multinomial logistic regression model to identify patient-level factors associated with opioid choice, as well as ICU-level variability using the adjusted median odds ratio (aMOR). **Results:** Among 17,898 admissions in 20 ICUs who met inclusion criteria, fentanyl was the most frequent initial opioid infusion (78.6%; n = 14,060), followed by hydromorphone (16.3%, n = 2,917) and morphine (5.1%; n = 921). Over time, fentanyl use decreased (89.0% [n = 1,468/1,650] in 2013; 75.0% in 2019 [n = 1,763/2,351]; P < 0.001), as did morphine use (7.7% [n = 127/1,650] to 3.2% [n = 75/2,351]; P < 0.001), while hydromorphone use increased (3.3% [n = 55/1,650] to 21.8% [n = 513/2,351]; P < 0.001). Surgical patients were more likely to receive hydromorphone than fentanyl (adjusted odds ratio [aOR], 1.52; 95% confidence interval [CI], 1.32 to 1.74) and less likely to receive morphine (aOR, 0.81; 95% CI, 0.68 to 0.96). We observed substantial inter-ICU variability in opioid use: adjusted median odds ratio (aMOR), 14.5 (95% CI, 7.3 to 25.7) for hydromorphone compared with fentanyl; aMOR, 5.2 (95% CI, 3.11 to 9.2) for morphine. **Conclusions:** Across 20 ICUs in Alberta, Canada, there were temporal changes and significant inter-ICU variability in opioid-prescribing practices for patients receiving mechanical ventilation. Further research is warranted to explore drivers of such substantial inter-ICU variability and associations between opioid selection and clinical outcomes to support evidence-based guidelines. RéSUMé: OBJECTIF: Les données probantes éclairant le choix de l’opioïde chez les personnes recevant une ventilation mécanique aux soins intensifs (USI) demeurent limitées, et les lignes directrices actuelles considèrent les opioïdes comme interchangeables. Nous avons cherché à décrire les tendances temporelles du choix du premier opioïde en perfusion chez les personnes gravement malades, ainsi que les facteurs qui y sont associés. MéTHODES: Nous avons mené une étude de cohorte historique portant sur des personnes ayant reçu une ventilation mécanique (VM) dans des USI de l’Alberta, au Canada, entre 2013 et 2019. Ont été incluses les personnes ayant reçu une première perfusion continue de fentanyl, d’hydromorphone ou de morphine. Nous avons évalué les
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