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Persistent Postoperative Opioid Use Seen in Approximately 6% of Patients

April 12, 2017
In patients deemed opioid-naive, postoperative opioid use >3 months was approximately 6%; while patients on chronic opioid therapy prior to surgery had a 2-fold higher risk of persistent opioid use after surgery.

Interview with Chad M. Brummett, MD, and Jennifer P. Schneider, MD, PhD

A small percentage of patients will remain on pain medicine for >3 months after undergoing surgery. What’s more, the risk factors associated with persistent opioid use will sound familiar to physicians assessing risk factors for opioid use among their patients: “preoperative tobacco use, alcohol and substance abuse disorders, mood disorders, anxiety, and preoperative pain disorders," according to the findings of a new study published in JAMA.1

For many patients, surgery is the first point of exposure to opioid analgesics, but unfortunately, few studies look at why some patients may be more prone to opioid reliance than others. The challenge is not only to get prescribers more aware of these patient risk factors, but also to understand why they exist, said Chad M. Brummett, MD, lead author of the new study,

“We need more research,” Dr. Brummett told Practical Pain Management. “This is something that our group is actively working on—looking at patient characteristics and genetic factors associated with persistent [opioid] use after surgery and misuse after surgery, as a way to help screen and help think through what patients actually need.”

Researchers are looking into risk factors for long-term opioid use after surgery.

Persistent Postoperative Opioid Use: A Relevant Clinical Problem

The new study used insurance claims data including 36,177 patients, 80.3% (n=29,068) of which had minor surgical procedures and 19.7% (n=7,109) had major procedures. The groups’ opioid doses were similar, showing no difference in opioid prescriptions in the 30 days prior to surgery: 225 mg oral morphine equivalents (OMEs) for both groups. That would equate to 45 tablets of 5-mg hydrocodone or 30 tablets of 5-mg oxycodone, the authors noted.

The incidence of persistent postoperative opioid use was similar between the groups: 5.9% of patients (n=1711) who received a minor surgery filled an opioid prescription between 90 to 180 days following the procedure, compared with 6.5% of patients (n=465) who received a major surgery (odds ratio, 1.12; 95% CI, 1.01-1.24).

“New persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders. This suggests its use is not due to surgical pain but addressable patient-level predictors. New persistent opioid use represents a common but previously underappreciated surgical complication that warrants increased awareness,” the authors wrote.

Patient factors that appeared to be more associated with persistent postoperative opioid included tobacco use, alcohol and substance abuse disorders, and comorbid conditions. Moreover, anxiety, depression, and various preoperative pain disorders, including back pain, neck pain, arthritis, and centralized pain conditions, were all independently associated with continued postoperative opioid use, the authors noted.

According to Dr. Brummett, the need to raise awareness among providers about these patient-level factors is important. There also could have been missing information about these factors, considering the research relied on claims-based data.

For instance, while some patients may have a formal diagnosis of depression, other may not. The same could be said for any possible markers of abusive behavior, or if patients were suffering from some type of chronic pain condition heading into the surgery, Dr. Brummett explained.

However, doctors should be careful not to lump pre-existing chronic pain disorders and behavioral health problems together, according to Jennifer P. Schneider, MD, PhD, a physician certified in Internal Medicine, Addiction Medicine, and Pain Management.

Dr. Schneider cited a recent article by Davis et al that found a significant category of patients who are at first may be prescribed opioids for a painful condition, but then find the opioids useful for relieving emotionally-driven pain.2

“There is now increasing evidence that some opioids, especially oxycodone, are effective for treating anxiety, depression, etc,” Dr. Schneider told Practical Pain Management. “So it makes sense that patients who are initially prescribed these drugs for some pain problem [such as, in this study, for some type of surgery], find it very helpful and continue taking it. Sometimes these patients don’t even recognize what’s going on, so it’s not that they are addicts or abusers.” Instead, health care providers need to recognize these patients require behavioral health treatment.

Limitations of Claim-Based Data

Another possible criticism of claims-based research is that the cohort was not exclusively opioid-naïve, considering a portion of patients received opioids in the weeks leading up to the surgery.

“That’s where we had to have some sort of flexibility in terms of how we designed it. There are many providers out there who give patients prescriptions for opioids before their surgery. And patients go and fill them before the surgery, so that when they go home, they’re not having to run to the pharmacy to get their opioids,” Dr. Brummett explained.

“That’s a very typical care pathway. We thought it was inappropriate after having 11 documented months of not taking an opioid, to all of the sudden say these people are now no longer opioid-naïve because we don’t actually know they are taking them.”

However, the researchers did find an association with higher continued use for those patients, where patients receiving an opioid 30 days prior to surgery had almost 2-fold higher odds of persistent opioid use after surgery.

While the research may have its limitation, Dr. Brummett pointed out that great efforts were taken to show that a sizeable portion of patients appear to be taking opioid medications long after what is typically required to recover from a surgical procedure, regardless if it is major or minor.

Unfortunately, right now, research has just begun to look at how postoperative opioid prescribing could be extended by certain patient level factors, and Dr. Brummett hopes that acute pain management moves more towards a patient-centered approach, giving patients the pain management they need while protecting them from the risks involved.

This study was supported by funding from the Michigan Department of Health and Human Services. Also, study coauthor Jennifer F. Waljee receives research funding from the Agency for Healthcare Research and Quality. All conflicts of interest disclosures can be found by reading the full study, available here.

Last updated on: April 28, 2017
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Why Does Acute Postoperative Pain Become Chronic and Can It Be Prevented?
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