Increased Rates of New Persistent Opioid Use After Minor and Major Surgery

"Many patients receive their first exposure to opioids following surgery, but the incidence of new persistent opioid use after surgical care is not well defined."
"Many patients receive their first exposure to opioids following surgery, but the incidence of new persistent opioid use after surgical care is not well defined."

In a population-based study reported in JAMA Surgery, researchers from the University of Michigan Medical School found elevated rates of new persistent opioid use in patients undergoing both minor and major surgical procedures.1

Sales of prescription opioids and related deaths have quadrupled since 1999, underscoring the urgent need for effective solutions to this growing epidemic.2 Although the Centers for Disease Control and Prevention released guidelines in 2016 on opioid prescribing for chronic pain, there has been less focus on opioids prescribed for postoperative pain.3

"Many patients receive their first exposure to opioids following surgery, but the incidence of new persistent opioid use after surgical care is not well defined," wrote the authors of the present study. Using a database of members of a large managed care company, they aimed to determine the rate of new cases of postoperative persistent opioid use and associated risk factors.

The final cohort included 36,177 US adults (66.1% women; 72.1% white) who had filled an opioid prescription in the month before surgery or within 2 weeks after discharge, but not in the year before surgery.

Patients had undergone 1 of 13 common elective surgical procedures categorized as either minor (80.3%; varicose vein removal, laparoscopic cholecystectomy, laparoscopic appendectomy, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, and carpal tunnel surgery) or major (19.7%; ventral incisional hernia repair, colectomy, reflux surgery, bariatric surgery, and hysterectomy).

A random sample of 492,177 age-matched patients was included for comparison. Individuals in this group did not undergo surgery or fill an opioid prescription during a specified 12-month period; they were assigned a random fictitious surgery date.

The 2 groups showed similar rates of new persistent opioid use, defined as a prescription filled between 90 and 180 days after surgery: 5.9% in the minor surgery group vs 6.5% in the major surgery group. The rate was 0.4% in the nonsurgical comparison group.

  • preoperative tobacco use (adjusted odds ratio [aOR], 1.35; 95% CI, 1.21-1.49)
  • alcohol and substance abuse disorders (aOR, 1.34; 95% CI, 1.05-1.72)
  • mood disorders (aOR, 1.15; 95% CI, 1.01-1.30)
  • anxiety (aOR, 1.25; 95% CI, 1.10-1.42)
  • preoperative pain disorders (back pain: aOR, 1.57 [95% CI, 1.42-1.75]; neck pain: aOR, 1.22 [95% CI, 1.07-1.39]; arthritis: aOR, 1.56 [95% CI, 1.40-1.73]; and centralized pain: aOR, 1.39 [95% CI, 1.26-1.54])

The finding of similar rates of use between the minor and major surgery groups suggests "persistent opioid use may be less associated with postsurgical pain than addressable patient-level factors," the authors stated.

"Given the declining rates of morbidity and mortality following common elective surgical procedures, new persistent opioid use represents an important, common, and under-recognized complication of perioperative care.4, 5

Summary and Clinical Applicability

New persistent opioid use after surgery may be less related to pain than individual risk factors such as preoperative pain and mood disorders, substance abuse, and preoperative tobacco use.

Limitations and Disclosures

The study did not capture actual opioid use or severity of risk factors such as pain and mood disorders, and the results may not be generalizable to uninsured or underinsured patients.

Dr Brummett, Dr Waljee, and Dr Englesbe have received research funding from various sources listed in the article; the remaining authors reported no disclosures. 

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References

  1. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in us adults [published online April 12, 2017]. JAMA Surg. doi: 10.1001/jamasurg.2017.0504
  2. Fecho K, Lunney AT, Boysen PG, Rock P, Norfleet EA. Postoperative mortality after inpatient surgery: incidence and risk factors. Ther Clin Risk Manag. 2008;4(4):681-688.
  3. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain: United States, 2016. JAMA. 2016;315(15):1624-1645. doi: 10.1001/jama.2016.1464
  4. Birkmeyer JD. Progress and challenges in improving surgical outcomes. Br J Surg. 2012;99(11):1467-1469. doi: 10.1002/bjs.8933
  5. Goodney PP, Siewers AE, Stukel TA, Lucas FL, Wennberg DE, Birkmeyer JD. Is surgery getting safer? national trends in operative mortality. J Am Coll Surg. 2002;195(2):219-227. doi: 10.1016/S1072-7515(02)01228-0

 

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