COMMENTARY

Teen Surgery and Persistent Opioid Use

William T. Basco, Jr, MD, MS

Disclosures

April 18, 2018

Persistent Opioid Use After Surgery

Are teens who receive perioperative opioids at risk for later opioid use disorder?

A recent study[1] analyzed data from a large commercial claims database to determine whether adolescents' exposure to opioids after surgery was associated with persistent opioid use. The study included patients aged 13-21 years who underwent one of 13 surgical procedures (e.g., head and neck, abdominal, musculoskeletal, urologic). All of the teens had been naive to opioids for at least 11 months before their surgery.

The analysis determined whether the teens received an opioid prescription 30 days before the procedure (to capture those who filled a prescription before their surgeries) and for 2 weeks after the index procedure. The authors used two comparison groups:

  • Patients who underwent one of the procedures but who did not receive opioids for pain; and

  • A second group of teens in the health plans who had no procedure at all.

The main outcome of interest was "persistent opioid use after surgery," defined as at least one additional opioid prescription dispensed 90-180 days after the procedure. The investigators also prespecified that they would examine whether any of the specific procedure types were associated with persistent opioid use.

Study Findings

Among more than 146,000 opioid-naive teens and young adults who had surgery, 60.5% filled a prescription for opioids before or after the procedure, and 29.3% of the patients filled multiple prescriptions. Tonsillectomy/adenoidectomy comprised the largest group of surgical procedures (35.9%), with arthroscopic knee surgery (25.3%) and appendectomy (18.6%) being the next most frequent. Among all participants who had a surgical procedure and subsequent opioid treatment, 4.8% demonstrated persistent opioid use compared with 1.1% of the comparison participants who had surgery but did not fill an opioid prescription and 0.1% of the nonsurgical comparison group.

The frequency of persistent opioid use was highest among the teens and young adults who underwent colectomy (15.2%), followed by supracondylar fracture (7.4%) and cholecystectomy (7.3%). The remaining procedures were associated with persistent opioid use rates of 2.7%-5.2%.

In regression analysis that accounted for age, sex, surgical procedure, comorbid conditions, mental health diagnoses, and any previous chronic pain diagnoses, age (adjusted odds ratio [aOR], 1.07), female sex (aOR, 1.2), and the presence of a chronic pain diagnosis (aOR, 1.48) were positively associated with persistent opioid use. Other chronic conditions were not associated with persistent opioid use, nor were depression and anxiety. Substance use disorder was positively associated with persistent opioid use, as was filling the prescription before the procedure.

Among surgical procedures, cholecystectomy and colectomy were independently associated with persistent opioid use. Of interest, the three procedures associated with the highest doses of postoperative opioids were all orthopedic procedures, but none of them was associated with persistent opioid use during the follow-up months.

The investigators concluded that approximately 5% of the patients who underwent one of 13 index surgical procedures experienced persistent postoperative opioid use, at a frequency much higher than that among teens and young adults who were not exposed to surgical procedures.

Viewpoint

This study raises the concern that perioperative opioid exposure may prime some individuals toward future opioid use and even misuse. Persistent opioid use was found in 4.8% of surgical patients who received an opioid prescription compared with 0.1% of those in the nonsurgical group. This study doesn't answer all of the questions about whether opioid exposure, even for appropriate conditions (e.g., postoperatively), is related to later opioid use, but it clearly reinforces the need for us to all be careful stewards of opioid medications.

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