Opioid Epidemic Extends to Post-Surgical Patients

Opioid use that persists past normal surgical healing time has become so prevalent in the United States that a study published April 12 in JAMA Surgery called this overuse “one of the most common complications of elective surgery.”

The study, “New Persistent Opioid Use after Minor and Major Surgical Procedures in U.S. Adults,” found higher-than-expected rates of opioid consumption that could translate into millions of new, long-term opioid users, among a large group of privately insured patients following minor and major surgical procedures.

Perioperative prescribing for acute care has received little attention until now, said lead author Chad M. Brummett, M.D., an associate professor at the University of Michigan School of Medicine and director of clinical research in the Department of Anesthesiology. “The data in this study are among the first to quantify the serious scope of this problem,” he said.

Brummett and colleagues used a nationwide insurance claims dataset from 2013 to 2014 to identify U.S. adults aged 18 to 64 with no history of opiate use in the 11 months prior to surgery. For patients filling a perioperative opioid prescription, researchers calculated the incidence of persistent opioid use for more than 90 days among “opioid-naïve” patients after minor surgical procedures (for example, varicose vein removal, carpal tunnel surgery, and laparoscopic appendectomy) and major surgical procedures (examples: bariatric surgery, hysterectomy, and ventral incisional hernia repair).

“Persistent use” is defined as filling an opioid prescription, such as hydrocodone or oxycodone, between 90 and 180 days after surgery. This definition represents the time a normal surgical recovery would be expected from the procedures selected and is more conservative than the three-month definition of long-term postsurgical pain by the International Association for the Study of Pain, according to the study.

The final study group consisted of 36,177 patients, with 29,068 (80 percent) receiving minor surgical procedures and 7,109 receiving major procedures. The study group had a mean age of 44.6 years and was predominately female (29,913, or 66 percent) and white (26,091, or 72 percent).

The rates of new persistent opioid use were similar between the two surgery groups, ranging from 5.9 percent to 6.5 percent. The incidence in the nonoperative control group was only 0.4 percent. Risk factors associated with new persistent opioid use included preoperative tobacco use, alcohol and substance use disorders, anxiety, depression, and preoperative pain disorders.

“This study has important implications for psychiatrists because most of the risk factors [for opioid overuse] are psychiatric disorders,” said Andrew J. Saxon, M.D., a professor and director of the Addiction Psychiatry Residency Program at the University of Washington and director for the Center of Excellence in Substance Abuse and Treatment at the Veterans Administration Puget Sound Health Care System.

“Psychiatrists should be attentive to the risk history of their patients undergoing surgery,” he advised. Some patients are at a higher risk of addiction and introducing them to opioids can be like “setting a match to a powder keg,” he said.

Although the added sedation from opioids generally does not cause adverse interactions with psychiatric medications, physicians should be extra vigilant regarding patients taking benzodiazepines because of the risk of respiratory depression and other complications when combined with opioids, he said.

Saxon suggested that physicians follow the basic advisory on acute use of opioids contained in the “CDC Guidelines for Prescribing Opioids for Chronic Pain—United States, 2016,” issued March 18: “Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.”

A surprising finding in the study involved patients who received an opioid prescription from their doctors in the 30 days before surgery. The odds for these patients of persistent opioid use after surgery were almost twice as high, even after adjusting for variables.

Given that more than 50 million ambulatory surgical procedures are performed in the United States annually, the findings of the study suggest that more than 2 million people may transition to persistent opioid use following elective, outpatient surgery each year, said Brummett. Patients on Medicaid and the uninsured, groups that have shown high rates of opioid use, were not included in this research, but will be studied by this research group in the future, he said.

The multilevel, multivariate logistic regression model with data from U.S. Census Bureau geographic regions examined differences in persistent opioid use between surgical types while controlling for patient characteristics including age, sex, race and ethnicity, education, history of tobacco use, mental health disorders, and pain disorders. Regional variation was found, with higher rates of new persistent opioid use in the East South Central and West South Central United States.

Prolonged opioid use following surgery may not be a consequence of poorly controlled pain, according to researchers. The pain experienced after major procedures would be expected to be greater than for minor procedures, which could more likely result in continued opioid use for long periods. However, that was not the case. The study found that new persistent opioid use did not differ much between major and minor procedures.

Patients likely continued using opioids for reasons other than for treating the intensity of surgical pain, the study concluded. While overestimating the safety of this prescribed medication, patients may use an opioid medication for other purposes such as back and neck pain, headache, osteoarthritis, and insomnia or may use the drug to treat emotional pain and distress.

The study was funded by the Michigan Department of Health and Human Services and the Agency for Health Care Research and Quality. ■