10% of Cancer Patients: Persistent Opioid Use After Surgery

Fran Lowry

November 02, 2017

Among patients with cancer undergoing curative-intent surgery, "persistent" use of opioids is a common iatrogenic complication, researchers from the University of Michigan, Ann Arbor, say.

In a retrospective cohort study, 10% of patients who had surgery that was expected to cure their cancer were still filling opioid prescriptions 1 year after their operation, with daily opioid doses similar to those in long-term opioid users.

Such continued use poses a "substantial" burden on cancer survivors and calls for changes to prescribing guidelines, physician education, and patient counseling after surgery, write the authors.

The study was published online October 19 in the Journal of Clinical Oncology.

 "We have a large group here at the University of Michigan who are studying opioid use in general, but, as a surgical oncologist, I know that cancer patients are usually excluded from the studies because the thought is that if a patient has cancer, it must hurt, and so they need pain pills," senior author, Lesly A. Dossett, MD, from the university's Ann Arbor medical center, told Medscape Medical News.

If a patient has cancer, it must hurt, and so they need pain pills. Dr Lesly A. Dossett

"But the reality is that many of the patients that we operate on have very early-stage disease and are going to be cured by their surgery, so we don't want to turn them into persistent opioid users," Dr Dossett said.

Persistent opioid use does not necessarily mean addiction, she clarified.

"It is very difficult to tease out addiction from large claims data, so we defined use as persistent if patients were continuing to fill opioid prescriptions a year after surgery, which is clearly outside the range for appropriate use," Dr Dossett said.

"It's impossible to determine whether they were taking narcotics for other injuries. Perhaps they hurt their back or had another injury. That is why we don't use the term 'addicted.' We can't make that claim with the data we have. But it is concerning that a year after surgery a sizeable number of people who were not using narcotics before are continuing to use them so long after the surgery,"

From a national data set of insurance claims, the Michigan researchers identified 68,463 patients who underwent curative-intent surgery from 2010 to 2014 for melanoma or breast, colorectal, lung, esophageal, or hepato-pancreato-biliary/gastric cancer and who filled opioid prescriptions.

Of these, 39,877 (58%) were opioid-naive, 16,063 (23%) were intermittent opioid users, and 12,523 (18%) were long-term opioid users.

Among the previously opioid-naive patients, 4159, or 10.4% (95% confidence interval, 10.1% to 10.7%) developed persistent opioid use after their surgery.

The risk for persistent opioid use was greater among patients who also received adjuvant chemotherapy after their surgery (33% vs 16%) and among patients who got opioid prescriptions before their surgery (26% vs 20%).

"One year after their surgery, these patients continued filling prescriptions with daily doses similar to chronic opioid users, equivalent to 6 tablets per day of 5-mg hydrocodone," Dr Dossett said.

"The rate is higher in patients receiving adjuvant chemotherapy, and we think this is because some medical oncologists are prescribing narcotics to treat the peripheral neuropathy that's coming from the chemotherapy agents, even though the recommendations in the medical oncology literature state that peripheral neuropathy is not usually successfully treated with opioids," she said.

Dr Dossett explained that  patients sometimes go back to their primary care providers, who may tend to associate their cancer diagnosis  with pain.

The Michigan surgeon would like to see a global effort to reduce the amount of narcotics that are prescribed after surgery.

"Our hope in writing this paper is to point out that, especially in early-stage cancer patients, we need to be as concerned as we are about general surgery patients. Many are going to be cured, so we don't want to have chronic opioid use or addiction as a complication of our treatment," she said.

In fact, opioids after surgery may not even be necessary, Dr Dossett said.

"Our group in Michigan just published recommendations for opioid prescribing across 20 different surgeries. They were deliberately very conservative. Many people are on the front of the curve in reducing opioid prescriptions and feel comfortable transitioning to zero narcotics. It's done all over the world, in Canada, Europe, Africa. We have surgeons who go there and perform surgery and don't use any narcotics. I think the answer is to use much less than we are currently using and, possibly, zero," she said.

Findings Are "Concerning"

Commenting on this study for Medscape Medical News, Eduardo Bruera, MD, McGraw Chair in the Treatment of Cancer, University of Texas MD Anderson Cancer Center, Houston, said, "The finding that a small — 10% — but significant proportion of patients who received opioids for curative cancer surgery became persistent opioid users is concerning since the goal is to completely stop all opioids after the resolution of the surgical event."

More research is needed to understand who these patients are and who is prescribing their opioids, he said

It is unlikely that a surgical oncologist is continuing these prescriptions for such a long time, Dr Bruera added.

"Based on these findings, universal precautions, including screening for risk factors for chemical coping and early referral to supportive care or pain specialists, for patients who continue to report high pain intensity and request opioids should be implemented," he said.

The study was supported by the National Research Service Award postdoctoral fellowship, the National Institute on Drug Abuse, and the Michigan Department of Health and Human Services. Dr Dossett and Dr Bruera have disclosed no relevant financial relationships.

J Clin Oncol. Published online October 19, 2017. Abstract

Follow Medscape Oncology on Twitter: @MedscapeOnc

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