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Does Opioid Cessation Prior to Surgery Help or Hurt?

A new study found that preoperative chronic opioid use leads to more adverse events, but is tapering or stopping opioids before surgery the solution? PPM experts say perhaps not.

Interviews with Jennifer P. Schneider, MD, PhD, Jeffrey Gudin, MD, and Ofer Wellisch, MD

Patients receiving opioids prior to elective abdominal surgery had slightly longer hospital stays and were at higher risk of being discharged to a rehabilitation facility than opioid-naïve patients, according to  the results of a new stuy.1

According to lead author Jennifer F. Waljee, MD, MPH, MS, and colleagues, this study could “have important implications for patients anticipating surgery, and clinicians and surgeons seeking to optimize patient safety and postoperative outcomes.”

Clinicians debate the benefits of reducing opioids prior to surgery.“Chronic opioid use complicates management following surgery, and increases postoperative healthcare utilization and costs independent of other risk factors. Therefore, developing preoperative interventions that focus on opioid cessation and alternative pain treatment prior to elective surgery may improve the quality of surgical care delivered in the United States,” the authors concluded.

However, several pain specialists questioned these conclusions. “It is unrealistic to get somebody off opioids before surgery if they are on anything more than a minor dose,” Jennifer P. Schneider, MD, PhD, a physician certified in Internal Medicine, Addiction Medicine, and Pain Management, told Practical Pain Management. For patients taking small doses of opioids, it is much easier to do, but for patients taking significant amounts opioids, the cessation process will take more time, ideally months, she noted.

“It is not a practical thing, and one thing you can be sure of is if you start [opioid cessation] prior to surgery, it’s going to disrupt that person’s life.” Patients will have to start a serious tapering process in the lead up to surgery. Subsequently, those patients will be at risk of developing more severe pain and loss of function than when they were on the medication, she noted.

Also, most patients would not be interested in tapering off their opioids prior to surgery, Dr. Schneider pointed out, especially if those opioids have enabled them to maintain a level of functioning in their daily lives.

Ofer Wellisch, MD, a board-certified anesthesiologist, pain management, and addiction specialist at Englewood Hospital and Medical Center in Englewood, New Jersey, agreed. Patients taking chronic opioids typically will require more analgesia for their acute recovery. These higher dose levels can increase the risk for opioid-induced adverse effects, “which will increase length of stay and complications around the time of surgery,” something not unexpected for this patient type, Dr. Wellisch said.

Dr. Wellisch also noted that pain specialists typically will not choose to take patients off their opioid medications in preparation for surgery. However, doctors can refrain from increasing opioid dosage prior to surgery, or even pull back the dosage somewhat in order to increase the patient’s sensitivity to opioids in the acute phase of their recovery.

The Study Findings

The study investigators used insurance claims data from 200,005 patients receiving 1 of 4 elective surgical procedures, including:

  • Hysterectomy (n= 109,035)
  • Bariatric surgery(n=55,505)
  • Reflux (n=12,629)
  • Ventral Hernia (n=22,836)

Out of this group, 8.8% had taken opioids prior to surgery. This was defined as having “filled at least 1 opioid prescription within 30 days of their procedure and at least another prescription of an opioid 30 to 90 days prior to the procedure,” to indicate chronic opioid use, according to the authors.1

While oral morphine equivalent doses varied for patients receiving opioids prior to their surgeries, the authors reported that preoperative opioid users on average stayed in the hospital after surgery longer compared to other patients, at 2.9 days versus 2.5 days, P < 0.001, respectively.

The authors also reported that preoperative opioid users were more likely to be readmitted to the hospital within 30 days of surgery or be discharged to a rehabilitation facility, compared to patients not using opioids prior to surgery, at 4.5% versus 3.6%, P < 0.001 and 3.6% versus 2.5%, P < 0.001, respectively. However, there were no statistically significant differences found in the indications for hospital readmission based upon preoperative opioid use.

Dr. Schneider questioned the strength of the study’s conclusions, noting that the data did not provide any indication of pain severity, disease status, or level of functioning, which could have helped explain why those patients were prescribed opioids or why they required longer hospital stays or rehabilitation following surgery.

The study also found that if patients suffered from any comorbid psychological conditions, including depression, anxiety, and substance use disorder, outcomes were worse. “If patients with more comorbidities and psychological problems go into surgery, they are more likely to have longer hospital and readmissions stays than their healthier counterparts, regardless of opioid usage,” said Jeffrey Gudin, MD, director of Pain Management and Palliative Care at Englewood Hospital and Medical Center in Englewood, New Jersey.

Drs. Schneider, Gudin, and Wellisch all stated that risk minimization strategies should be employed to better facilitate safe, effective pain management in the perioperative setting. To this aim, increasing professional awareness and education into the subject is significant, Dr. Schneider pointed out. Drs. Gudin and Wellisch noted that pushing towards multimodal techniques and enhanced surgery recovery protocols through multidisciplinary care will be key facets to improving post-surgical outcomes for patients, including those living with chronic pain.

The study described in this article was supported by a Mentored Clinical Investigator Award given to study author Dr. Waljee, who also reported receiving funding from the Agency for Healthcare Research and Quality, the American College of Surgeons, and the American Foundation for Surgery of the Hand. She also served as an unpaid consultant for 3M Health Information systems. Study co-author Chad M. Brummett, MD, receives research funding from the National Institutes of Health and the University of Michigan Medical School Dean’s Office, He also serves as a consultant for Tonix Pharmaceuticals and receives research funding from Neuros Medical Inc. No other authors reported and financial relationships and no authors reported any conflicts of interest.

Last updated on: December 28, 2018
Continue Reading:
Opioid-Maintained Patients Who Require Surgery

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