The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use

Charles Katzman, BS; Emily C. Harker, BS; Rizwan Ahmed, BS; Charles A. Keilin, BS; Joceline V. Vu, MD; David C. Cron, MD, MS; Vidhya Gunaseelan, MS, MHA; Yen-Ling Lai, MS, MPH; Chad M. Brummett, MD; Michael J. Englesbe, MD; Jennifer F. Waljee, MD, MPH

Disclosures

Annals of Surgery. 2021;274(5):e410-e416. 

In This Article

Discussion

Periodic, nonchronic opioid use before surgery is common, and the intensity of exposure varies. In this cohort of adults undergoing common surgical procedures, we observed that 41% of patients had filled an opioid prescription in the year before surgery, and these patients were 2 to 12 times more likely continue to fill opioids for a prolonged period after surgery when compared to opioid-naïve patients. Patients with low-dose, recent, moderate use were the most at risk, with more than 1 out of every 2 patients developing persistent use after surgery. These patients were also more than two and a half times as likely to develop persistent use than remote intermittent users. Given the prevalence of opioid use in the United States, identifying preoperative opioid exposure is critical to ensure safe prescribing and effective pain management after surgery.

Prior work has demonstrated that opioid-naïve patients are at risk for developing new persistent use after surgery, and patients with ongoing chronic use continue to fill opioids after surgery.[7,24] The findings demonstrate a knowledge gap for patients with nonchronic, periodic preoperative opioid use, whose trajectories of postoperative use are poorly understood. Similar to other studies, we observed that patient characteristics, such as lower education, sedative use, tobacco use, alcohol use, substance use disorders, and concurrent pain or mood disorders, increase the risk of prolonged postoperative fills. Although we also observed a higher rate of persistent use among patients that filled Tramadol before surgery, a significant amount of patients filled opioids of multiple types, and the ability to discern a correlation between the probability of prolonged use and receipt of a specific formulation is challenging.

With respect to preoperative opioid exposure, it is possible that nonchronic, periodic users develop tolerance to standard opioid regimens, resulting in the need for higher doses to achieve the same analgesic effects. Poor pain control in the immediate postoperative period is also correlated with the risk of developing a persistent postoperative pain state, which could possibly lead to prolonged opioid use and contribute to the findings we observed in this study.[25,26]

This study has several important limitations. First, our analysis is restricted to billing claims of commercially insured patients, which may not be representative of all patients receiving surgical care. Although we are able to capture patients with a broad range of insurance plans, we do not have data regarding patients who receive coverage from federally funded plans including Medicare and Medicaid, and the uninsured. Second, our data was taken from insurance claims that only track the fill date and quantity of opioid prescriptions. Because of this, we cannot describe actual opioid use. Similarly, we were unable to identify patients who may have been prescribed an opioid but did not fill their prescription, and cannot determine the indication for which preoperative opioid prescriptions were provided. This limitation also means that we were unable to determine the indication for which preoperative opioid prescriptions were provided, and thus unable to determine if these prescriptions were related to their surgical conditions. However, we did attempt to control for this by excluding patients who had multiple surgical procedures from our study.

Despite these limitations, our study findings highlight an important opportunity to screen for risk of persistent opioid use for patients undergoing surgery. Notably, periodic opioid use, especially if remote or short duration, may not be captured in the routine preoperative history. For example, if prescriptions are filled through a different health system or are not disclosed by the patient, they may not populate into electronic medical records. Querying patients regarding preoperative opioid use is important, and recent legislation to identify fill patterns of scheduled medications could augment these efforts. For example, prescription drug monitoring programs (PDMPs) are statewide databases that track controlled substance fill histories for patients, allowing physicians to identify patterns of use and abuse before writing additional prescriptions.[27,28] Currently, providers often utilize the PDMP the day before or day of surgery, leaving too little time for preoperative education or intervention. Checking the PDMP when the surgery is scheduled, rather than just before writing the prescription, would ensure that enough time is allotted for coordination of perioperative intervention in higher-risk patients. Given that not all providers use the PDMD, preoperative history should also include targeted questions regarding history of opioid prescription in the last 12 months. Our findings support the notion that routine use of PDMPs and more targeted history-taking during initial preoperative visits could be an important avenue to identify both chronic and nonchronic, periodic preoperative opioid users before surgical care.

Although PDMPs can be useful for identifying at-risk patients, the approach to pain management may still be quite challenging in this cohort. One approach to this problem includes considering the use of multimodal analgesia. For example, Richman et al demonstrated that continuous peripheral nerve block analgesia provided better postoperative pain relief with fewer side effects than opioids.[29] Other analgesic alternatives worth considering include tricyclic antidepressants, gabapentin, local anesthetics, and regional anesthetics.[25,30,31] If alternative analgesics are not an option, prescribers should strongly consider prescribing opioids with a lower likeability and decreased potential for misuse whenever possible.[32,33] Finally, surgeons should communicate with primary care providers regarding coordination of opioid prescribing and the expected course of postsurgical pain to avoid disjointed and overlapping opioid prescribing.[31]

In summary, nonchronic, periodic preoperative opioid use is common before surgery and represents an underappreciated but large group of patients who undergo surgical procedures. Nonchronic, periodic preoperative opioid use places patients at risk for persistent opioid use after surgery. This demonstrated risk highlights a clear need to identify these patients preoperatively, to optimize their perioperative pain control and to minimize future opioid-related morbidity and mortality. These goals can be achieved, in part, by using PDMPs regularly, placing a greater emphasis on other modes of postoperative pain control, and increasing the coordination of follow-up pain management between surgeons, primary care providers, and pain specialists.

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