Opioid-Naive Patients at Low Risk of Opioid Reliance After Surgery
Postoperative opioid use is routine for patients recovering from major surgeries. But there is concern that patients may be at high risk of falling into prolonged opioid use after their procedures,1 which could lead addiction, among other problems.2 However, for opioid-naïve patients, the actual risk of persistent opioid use after a surgery may be surprisingly low.
A recent retrospective study of nearly 40,000 opioid-naïve patients receiving opioids after major surgery found >1% of patients were still taking an opioid medications a year after their surgery.3 The study, which was published in JAMA Surgery, is a follow-up to a 2014 study that found that 3% of previously opioid-naïve patients continued using opioids 3 months after a major elective surgery.4
This is the latest study to show that certain patient groups are more susceptible to persistent opioid use than others. “Our study further indicates that interventions for preventing long-term opioid use in opioid-naïve surgical patients are best targeted to individuals predisposed to this problem,” the authors wrote.
Avoiding Persistent Opioid Use
Acute postoperative pain is common and is often moderate to severe in intensity; in fact, more than half of patients report dissatisfaction with their pain management.5-6 Undercontrolled postoperative pain can lead to the development of chronic pain conditions.
Early this year, the American Society of Anesthesiologists (ASA) published new guidelines on managing postoperative pain, calling for increased use of multimodal, opioid-sparing approaches to managing postoperative pain, including the use of site-specific anesthesia, acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs), and non-drug interventions like cognitive behavioral therapy (CBT).7
According to Hance A. Clarke, MD, PhD, FRCPC, from the Pain Research Unit, Department of Anesthesia and Pain Management, at the Toronto General Hospital in Toronto, Canada, their new study showed that the vast majority of patients were able to get off of opioids by 1 year post-surgery. However, these patients were opioid-naïve – an ideal circumstance. Other patient groups may be far more at risk.
Using database information on prescriptions handed out to Ontario residents, Dr. Clarke and his colleagues followed 39,140 patients, 53% of which had received 1 or more opioid prescriptions within 90 days of being discharged from the hospital. Patient characteristics included:
- 66 years or older
- Opioid-naïve (no registered prescription in the prior year)
- Underwent a specific major elective surgery (from 2003 to 2010)
Any individuals that required palliative care services within 1 year before or after the surgery were excluded from the study, as researchers measured the proportion of patients still on opioid therapy at 180, 270, and 365 days after the surgery.
Only 168 out of the 37,650 surviving patients (0.4%; 95%CI, 0.3%-0.5%) were still receiving an opioid medication one year after their respective surgeries. The highest risk of this happening correlated to the type of procedure, as a sizeable portion of the patients had received open or minimally invasive lung resection procedures, at 37 of 2212 patients (1.7%; 95%CI, 1.2%-2.3%) and 9 of 669 patients (1.3%; 95%CI, 0.6%-2.5%), respectively. These procedures may present a higher risk given their association with increased risks for chronic postsurgical pain.8
Taken together, the 2014 study and follow-up show 97% of the study population were able to get off opioids by 6 months, and most patients were off of opioids by 1 year, Dr. Clarke told Practical Pain Management. Indeed, the research falls in line with other studies that have found the individual risk of long-term opioid use for opioid-naïve patients to be fairly low.9
Preventing Opioid Reliance After Surgery
Instead, the risk of persistent opioid use after a surgery is more relevant for patients classified in the “high-risk group,” Dr. Clarke explained. Some surgeries could place patients in this group, like thoracotomy and radical breast cancer surgery, which typically require a much different post-operative course.
“In our 6 month data we found that patient related factors associated with significantly higher risks of prolonged opioid use, including younger age, lower household income, specific comorbidities,” like diabetes, heart failure, and pulmonary disease, “and use of specific drugs preoperatively,” such as benzodiazepines, selective serotonin reuptake inhibitors, and angiotensin converting enzyme inhibitors, Dr. Clarke said.
But some of the most obvious risk factors – having pre-operative pain and opioid use – are just as relevant, and yet account for 12.5% of the surgical population, said Dr. Clarke. Some patients may also have negative thoughts going into a surgery, causing them to catastrophize their pain – a pattern now linked with worse post-surgical outcomes.
“These are the patients that struggle, and the health care system does not do a good job of managing (them),” said Dr. Clarke, who agreed with the notion there is a lack of discussion about guiding practitioners to get their patients off of opioid medications in a safe, timely manner after a major surgery.
In 2014, Cr. Clarke and his colleagues designed the Transitional Pain Service (TPS) at Toronto General Hospital, a multidisciplinary program that identifies and treats patients at high-risk for persistent opioid-use and guides them through post-surgery recovery through careful monitoring and multimodal pain management.10
“There is minimal education in medical school and most training programs are dedicated to opioid prescribing practices. Similar to flying a plane, if you are going to take off you should know how to land it.”