Abstract and Introduction
Background: While preoperative gabapentinoids are commonly used in surgical multimodal analgesia protocols, little is known regarding the effects this therapy has on prolonged postsurgical opioid use. In this observational study, we used data from a large integrated health care system to estimate the association between preoperative day-of-surgery gabapentinoids and the risk of prolonged postsurgical opioid use.
Methods: We identified adults age ≥65 years undergoing major therapeutic surgical procedures from a large integrated health care system from 2016 to 2019. Exposure to preoperative gabapentinoids on the day of surgery was measured using inpatient medication administration records, and the outcome of prolonged opioid use was measured using outpatient medication orders. We used stabilized inverse probability of treatment-weighted log-binomial regression to estimate risk ratios and 95% confidence intervals (CIs) of prolonged opioid use, comparing patients who received preoperative gabapentinoids to those who did not and adjusting for relevant clinical factors. The main analysis was conducted in the overall surgical population, and a secondary analysis was conducted among procedures where at least 30% of all patients received a preoperative gabapentinoid.
Results: Overall, 13,958 surgical patients met inclusion criteria, of whom 21.0% received preoperative gabapentinoids. The observed 90-day risk of prolonged opioid use following surgery was 0.91% (95% CI, 0.77–1.08). Preoperative gabapentinoid administration was not associated with a reduced risk of prolonged opioid use in the main analysis conducted in a broad surgical population (adjusted risk ratio [adjRR], 1.19 [95% CI, 0.67–2.12]) or in the secondary analysis conducted in patients undergoing colorectal resection, hip arthroplasty, knee arthroplasty, or hysterectomy (adjRR, 1.01 [95% CI, 0.30–3.33]).
Conclusions:In a large integrated health system, we did not find evidence that preoperative gabapentinoids were associated with reduced risk of prolonged opioid use in patients undergoing a broad range of surgeries.
As the use of multimodal analgesic techniques increases in response to the opioid crisis, it is important to investigate the role and appropriateness of gabapentinoids in surgical pain management. Between 2006 and 2007, 3 systematic reviews evaluating perioperative gabapentinoids and postoperative pain were published, contributing to widespread acceptance that gabapentinoids could help reduce pain and opioid consumption in the immediate postoperative period.[1–3]
More recently, a meta-analysis by Verret et al found that perioperative use of gabapentinoids was not associated with a meaningful reduction in acute, subacute, or chronic pain. In December 2019, the US Food and Drug Administration (FDA) issued a safety communication warning of respiratory depression when gabapentinoids are used concurrently with central nervous system depressants such as opioids. This communication also discussed growing rates of gabapentinoid misuse and abuse. Despite the fact that gabapentinoid use for preoperative pain is not approved by the FDA, clinical guidelines increasingly recommend use of preoperative gabapentinoids as a component of multimodal analgesia at surgery.[6–8] Likewise, as opioid-sparing techniques gained in popularity,[9,10] hospital protocols increasingly added off-label gabapentinoid use to surgical protocols.[11–13]
It remains unknown to what extent off-label use of gabapentinoids in perioperative pain management can safely reduce opioid consumption and long-term risks of opioid use in different surgical settings and patient populations. To address this knowledge gap, this study used a large surgical cohort of Medicare patients from an integrated health system to test the hypothesis that preoperative day-of-surgery gabapentinoid administration is associated with reduced prolonged opioid use following major surgical procedures.
Anesth Analg. 2021;133(5):1119-1128. © 2021 International Anesthesia Research Society