Review by Dr. Lindsay Rite
Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. Published online April 12, 2017e170504. doi:10.1001/jamasurg.2017.0504
A US data set taken from 2012-2014 was utilized to objectively determine the incidence of new persistent opioid use after minor and major surgical procedures. The incidence of persistent opioid use for more than 90 days among post-surgical opioid-naive patients (meaning no opioid prescription fulfillments from 12 months to 1 month prior to the procedure) was measured. The outcome of new persistent opioid use was defined as at least one opioid prescription fulfillment between 90 and 180 days after the procedure; this timeframe would presumably note post surgical recovery.
A priori prior data extraction. A multilevel, multivariate logistic regression model, was estimated to examine differences in persistent opioid use between surgical types while controlling for patient characteristics, including age, sex, race/ethnicity, education, history of tobacco use, mental health disorders, Charlson Comorbidity Index, pain disorders, and opioid prescription OME within the surgical time frame.
A total of 36,177 patients were included in this study. Inclusion criteria available upon request. A randomized age matched comparison cohort of patients who did not undergo surgery was utilized. A fictitious surgical date was assigned to these patients.
The incidence of new persistent opioid use was similar between the two groups. In the minor surgery group, 5.9% filled an opioid prescription between 3 and 6 months’ vs 6.5% in the major surgery group. By comparison, only 0.4% in the nonsurgical comparison group filled an opioid prescription in this same timeframe.
Tobacco use, alcohol and substance abuse disorders, and comorbid conditions increased the risk of new persistent opioid use among opioid-naive patients, regardless of surgical procedure. In addition, anxiety, depression, and other preoperative pain disorders (ie, back pain, neck pain, arthritis, and centralized pain conditions) were independently associated with continued postoperative opioid use.
Patients receiving an opioid prescription in the 30 days before surgery had almost 2-fold higher odds of persistent opioid use after surgery, even after adjustment for other covariates.
Regional differences were noted with almost double the incidence of new persistent opioid use in the West South Central and East South Central compared to the Middle Atlantic region of the US.
- Actual opioid consumption was not captured
- US based cohort
- Retrospective data collection
- Cohort was drawn from a large, population-based cohort of insured adults and their dependents, thus findings may not be generalizable to the uninsured, underinsured, and individuals 65 years and older.
In this study of a US cohort of previously opioid-naive patients, approximately 6% continued to use opioids more than 3 months after their surgery, and as such, prolonged opioid use was deemed to be the most common postsurgical complication.
The authors found that new persistent opioid use did not differ between major and minor procedures. Thus they concluded that it was likely that patients continue use of opioids for reasons other than intensity of surgical pain and that prolonged opioid use following surgery may not simply be a consequence of poorly controlled pain.
Findings suggest that in the US more than 2 million individuals may transition to persistent opioid use following elective surgery each year.
These findings highlight the commonality of new persistent opioid use representing a previously underappreciated surgical complication. The rate noted in this study warrants increased awareness, improved perioperative guidelines, and demand for comprehensive solutions.
Our Pain Specialists are acutely aware of this complication. Recently Dr. Lau piloted her surgical Wellness GMV to discuss this and other highly relevant topics. Despite the effectiveness of the GMV, patient plans required highly personalized prescription and as such they will be performed during follow-up visits instead of in a GMV format. In the future, Research Corner will discuss the evidence for alternative perisurgical therapies.
Additional note from Dr. Yu: There is probably an "at risk" group of patients that we can identify, who have a higher chance of poor outcome at least in terms of pain management, who will have prolonged usage of opioids, with resultant decreased of QOL post surgery. The interesting unanswered questions are whether pre-surgical engagement/education and perioperative intervention can lead to improved outcome. My gut tells me we probably can make a dramatic difference.
Additional references, Canadian Cohort:
Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425-430.
Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014; 348:g1251.