Long-term Opioid Use Major Risk After Surgery

Diana Phillips

April 12, 2017

New persistent opioid use after surgery is an increasingly common and underrecognized complication of perioperative care, new data suggest.

In a cohort of privately insured patients in the United States, 6% of those who underwent elective minor or major surgical procedures continued to use opioids for at least 90 days after surgery.

The finding indicates that prolonged opioid use may be the most common complication after elective surgery, Chad M. Brummett, MD, from the Division of Pain Medicine in the University of Michigan Medical School Medical School Department of Anesthesiology, Ann Arbor, and colleagues report in an article published online today in JAMA Surgery.

The investigators also determined that the rates of new persistent opioid use did not differ among patients who underwent minor vs major surgical procedures, "suggesting that prolonged opioid use is not entirely due to surgical pain," they write. However, they note that patients with chronic pain and certain lifestyle and behavioral health conditions before the operations had a higher rate of persistent prescriptions after surgery.

To determine the incidence of new persistent opioid use and associated risk factors among individuals receiving minor or major surgical procedures performed between 2013 and 2014, the investigators examined insurance claims for adult members of a large national managed care company. They included claims from January 1, 2012, to June 30, 2015, to account for the 12-month preoperative and 6-month postoperative period. Patients who underwent 13 common minor and major elective surgical procedures were included in the analysis.

The investigators also included a 10% sample of patients who did not undergo surgery and who did not fill an opioid prescription during a 12-month period for comparison.

Of 36,177 patients who met the inclusion criteria, 29,068 (80.3%) underwent minor surgical procedures and 7109 (19.7%) underwent major procedures. The minor procedures included varicose vein removal, laparoscopic cholecystectomy, laparoscopic appendectomy, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, and carpal tunnel. The major procedures included ventral incisional hernia repair, colectomy, reflux surgery, bariatric surgery, and hysterectomy.

The median total dose of all opioid prescriptions during the 30 days before surgery to 14 days after discharge was the equivalent of 45 tablets of 5-mg hydrocodone or 30 tablets of 5-mg oxycodone.

The incidence of new persistent opioid use, which was defined as filling an opioid prescription between 90 and 180 days after surgery, was similar between patients in the minor and major surgery groups, at 5.9% and 6.5%, respectively. In comparison, only 0.4% of individuals in the nonsurgical comparison group filled an opioid prescription during the study period between 90 to 180 days after a randomly assigned, fictitious surgery date.

The finding suggests that "prolonged opioid use following surgery may not simply be a consequence of poorly controlled pain," the authors write. "The pain experienced after major procedures would be expected to be greater than for minor procedures, which could be more likely to result in continued opioid use for long periods."

The risk for new persistent opioid use was higher among patients who smoked and those with alcohol and substance abuse disorders, comorbid conditions, anxiety, depression, and other preoperative pain disorders, such as back pain, neck pain, arthritis and centralized pain conditions.

"[B]ecause opioids are prescribed medications, patients may overestimate their safety and use opioids intended for postsurgical pain for other symptoms, such as back and neck pain, headaches, osteoarthritis, and insomnia, for which opioids are not effective," the authors write.

The observed increased risk for prolonged opioid use among patients with mental health conditions is consistent with earlier research, according to the authors, who hypothesize that "patients may continue to use their postoperative opioids to treat emotional pain and affective distress."

Regional variation in new persistent opioid use was also observed, "with higher rates of new persistent opioid use in the East and West South Central United States," the authors write.

"Given the declining rates of morbidity and mortality following common elective surgical procedures, new persistent opioid use represents an important, common, and underrecognized complication of perioperative care," the authors write.

"Approximately 50 million ambulatory surgical procedures were performed in the United States in 2010; thus, our findings suggest that more than 2 million individuals may transition to persistent opioid use following elective, ambulatory surgery each year."

Although the epidemic of opioid overuse and abuse has received significant attention recently, "there has been little attention placed on postoperative prescribing," the authors write. "To our knowledge, there are currently no normative data for postoperative opioid prescribing to guide practice, and as such, it has become an issue of convenience and little attention has been placed on the potential morbidity to follow."

The findings point to the need for increased attention to postsurgical opioid prescribing practices, Dr Brummett said in an interview with Medscape Medical News. "There also needs to be a greater emphasis on educating surgeons around when to prescribe opioids and for how long, and when to refer patients with other conditions who are vulnerable to persistent opioid use to appropriate specialists."

This recommendation is consistent with that of panel of US Food and Drug Administration experts who advocated for mandatory physician training on the risks of prescription opioids, as well as alternatives for pain management, as reported recently by Medscape Medical News.

Dr Brummett disclosed relationships with Tonix and Neuros Medical and support from the National Institutes of Health and the University of Michigan Dean's Office for the Michigan Genomics Initiative. Dr Waljee disclosed relationships with 3M Health Information and research funding from the Agency for Healthcare Research and Quality, the American College of Surgeons, and the American Foundation for Surgery of the Hand. Dr Brummett, Dr Waljee, and Dr Englesbe have received funding from the Michigan Department of Health and Human Services.

JAMA Surg. Published online April 12, 2017. Full text

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