From the Journals

Preoperative opioid use linked to worse outcomes following abdominal surgery


Key clinical point: Preoperative opioid use is associated with worse postoperative outcomes following abdominopelvic surgery.

Major finding: Preoperative opioid users had 9.2% higher costs and 12.4% longer LOS, with higher ORs for complications and readmissions, than patients who did not take opioids.

Data source: Retrospective analysis of data on 2,413 abdominopelvic surgery patients during 2008-2014.

Disclosures: Study funded by grants awarded to Mr. Cron from the 2015 AOA Carolyn L. Kuckein Student Research Fellowship and the Blue Cross Blue Shield of Michigan Foundation Student Research Award. Authors reported no relevant financial disclosures.

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Surgeons must do more to curb opioid epidemic

The opioid epidemic is probably the biggest health care problem in the United States, and it’s getting worse. Opioids are absolutely affecting surgical outcomes on a large scale. Unfortunately, there’s no great solution in terms of how to better manage these patients – in a perfect world, we’d take the time to wean them off opioids before operating, but that isn’t very pragmatic. With such a large and expanding proportion of our patients presenting to the operating room on long-term opioids, we have developed a new cohort of high-risk surgical patients over the past several years.

Dr. Michael Englesbe
I do not take a detailed pain history and develop a preoperative pain management plan for my patients, but I should. I suspect this is true for the majority of other surgeons also. The push-back on this is “My patients do great and I am too busy.” These are reasonable comments, but many patients with even minor procedures go from being opioid naïve to chronic opioid users after surgery. We surgeons need to own this problem for the long-term health of our patients. Also, overprescribing can have devastating implications within our communities, and surgeons need to be part of the solution to this problem.

Michael J. Englesbe, MD , is a professor of surgery at the University of Michigan, Ann Arbor, and a coauthor on this study.



Surgeons need to do more to identify patients who are taking opioids preoperatively, because this is a population that appears to be at a higher risk of worse surgical outcomes, according to a large retrospective investigation.

“Opioid users represent a potentially high-risk surgical population and may require tailored perioperative care [and] the prevalence and clinical impact of this problem in the general surgery population remain unclear,” wrote the authors of a study, led by David C. Cron, a medical student of the University of Michigan, Ann Arbor. “Given the impact of pain control and gastrointestinal function on hospital stay, it is intuitive that opioid users may have increased hospital length of stay (LOS) and may incur more costs [and] also be at higher risk for surgical complications.”

The study was published in the Annals of Surgery (2017;465[4]696-701).

Mr. Cron and his coauthors made a study cohort retrospectively from abdominopelvic surgery patients from the Michigan Surgical Quality Collaborative (MSQC) database who had surgery between 2008 and 2014. All patients were treated at the University of Michigan, and were admitted within 2 days of undergoing their operation. Any patient with data indicating use of buprenorphine prior to surgery, or those were who opioid naive before admission but received opioids after being admitted, were excluded.

Investigators found a total of 3,107 patients in the MSQC database that underwent abdominopelvic surgery at the University of Michigan during the designated time frame; from that group, 2,413 were ultimately found to match the inclusion criteria for the study. The primary outcomes were 90-day total hospital costs, along with patient LOS, and 30-day rates of complications and readmissions. Data underwent covariate risk adjustment to account for age, race, gender, body mass index, insurance class, and other factors.

“Major complications are recorded by the MSQC and include: surgical site infection, deep venous thrombosis, acute renal failure, postoperative bleeding requiring transfusion, stroke, unplanned intubation, fascial dehiscence, prolonged mechanical ventilation longer than 48 hours, myocardial infarction, pneumonia, pulmonary embolism, sepsis, vascular graft loss, and renal insufficiency,” the authors noted.

Of the 2,413 subjects overall, 502 (20.8%) were found to use opioids before surgery. Differences between opioid users and nonusers were not significant in terms of age (P = .10), gender (P = .76), and race (P = .78). After adjustment, data indicated that preoperative opioid users had 9.2% higher hospital costs than nonusers (95% confidence interval, 2.8%-15.6%, P = .005) and 12.4% longer hospital stay (95% CI, 2.3%-23.5%; P = .015). Complications and readmission rates were quantified by odds ratios, which were also found to be significantly higher in subjects who were preoperative opioid users: OR = 1.36 (95% CI, 1.04-1.78; P = .023) and OR = 1.57 (95% CI, 1.08-2.29; P = .018), respectively.

The study had some limitations, including being conducted at a single center and potentially not generalizable to other types of health care facilities and population types. Additionally, information on opioid dosage and duration of use was lacking, making it that “possible that some opioid users in our study were using opioids over a shorter time period for pain related to their surgical disease,” according to the investigators.

“These results argue the potential cost-effectiveness of intervention in this unique patient population,” Mr. Cron and his colleagues concluded. “Opioid use is a potentially modifiable risk factor, and major surgery can provide powerful leverage to improve health behavior [and] our institution has implemented a preoperative program to optimize high-risk patients for surgery.”

Mr. Cron received funding from the 2015 AOA Carolyn L. Kuckein Student Research Fellowship and the Blue Cross Blue Shield of Michigan Foundation Student Research Award for this study. He and his coauthors reported no relevant financial disclosures.

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