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Common surgeries linked to chronic opioid use among opioid-naive patients

Key clinical point: Common surgeries increase the risk of chronic opioid use in opioid-naive adults, especially among those using antidepressants or benzodiazepines before their operations, and those with substance abuse histories.

Major finding: After adjustment for potential confounders, knee replacement increased the risk fivefold; open cholecystectomy almost fourfold; and total hip replacement and simple mastectomy almost threefold.

Data source: Insurance claims of more than 18 million people.

Disclosures: The authors had no disclosures. The work was funded in part by the Foundation for Anesthesia Education and Research and the Anesthesia Quality Institute. Claims data came from MarketScan (Truven Health Analytics).


 

FROM JAMA INTERNAL MEDICINE

References

Common surgeries increase the risk of chronic opioid use in opioid-naive adults, especially those using antidepressants or benzodiazepines before their operations, and those with substance abuse histories, according to an insurance claims analysis from Stanford (Calif.) University.

The researchers reviewed opioid prescribing in the first postop year – excluding the first 90 days – for 641,941 patients and compared that information with opioid prescribing for 18,011,137 adult patients who did not have surgery. None of the subjects had filled an opioid prescription in the previous year (JAMA Intern Med. 2016 Jul 11. doi: 10.1001/jamainternmed.2016.3298).

Chronic opioid use, defined as filling at least 120 days of opioid prescriptions within the first year of surgery, ranged up to 1.41% for total knee replacement, versus 0.136% in the nonsurgical controls. After adjustment for potential confounders, knee replacement increased the risk fivefold; open cholecystectomy almost fourfold; total hip replacement and simple mastectomy almost threefold; and laparoscopic cholecystectomy and open appendectomy almost twofold. Cesarean delivery increased the risk of chronic use by 28%.

With the exception of knee and hip replacements, “these procedures are not indicated to relieve pain and are not thought to place patients at risk for long-term pain ... Our results suggest that primary care clinicians and surgeons should monitor opioid use closely in the postsurgical period,” wrote Eric C. Sun, MD, PhD, of the department of anesthesiology, perioperative and pain medicine at Stanford (Calif.) University, and his colleagues.

Preoperative antidepressants and benzodiazepines carried about the same risk of chronic use as alcohol abuse (odds ratio 1.83; P less than .001), while drug abuse history increased the risk even more (OR 3.15; P less than .001). Male sex, age over 50 years, and history of depression were also associated with chronic use on multivariate analysis. Meanwhile, transurethral prostatectomy, laparoscopic appendectomy, functional endoscopic sinus surgery, and cataract surgery did not increase chronic use risk.

“Surgical patients, particularly those at higher risk for chronic opioid use, may benefit from techniques to reduce the risk such as multimodal analgesia and regional anesthesia, particularly in light of literature suggesting that these interventions may improve other perioperative outcomes ... Patients may also benefit from other preoperative and postoperative interventions, such as evidence-based psychobehavioral pain management skills,” the investigators said.

It wasn’t clear until now that even opioid-naive patients are at risk for opioid problems after surgery. Stanford’s investigation is not the first to link surgery and opioid abuse, but previous studies tended to focus on patients with preexisting use and more painful operations.

The study included prescriptions for oral and patch fentanyl, hydrocodone, oral hydromorphone, methadone, morphine, oxymorphone, and oxycodone. Hydrocodone cough remedies and acetaminophen/codeine analgesics were excluded.

Nonsurgical patients tended to be younger than their surgical peers (mean 42 vs. 44 years) and more likely to be male (49% vs. 26%).

The authors had no disclosures. The work was funded in part by the Foundation for Anesthesia Education and Research and the Anesthesia Quality Institute. Claims data came from MarketScan (Truven Health Analytics).

aotto@frontlinemedcom.com

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