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Surgery & Opioid Dependence Risk

Surgery & Opioid Dependence Risk
Author Information (click to view)

Eric C. Sun, MD, PhD

Instructor, Anesthesiology, Perioperative and Pain Medicine

Stanford University Medical Center

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Eric C. Sun, MD, PhD (click to view)

Eric C. Sun, MD, PhD

Instructor, Anesthesiology, Perioperative and Pain Medicine

Stanford University Medical Center

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Opioid-naïve patients undergoing surgery appear to be at higher risk for subsequent chronic opioid use. Clinicians should closely monitor these patients whenever they receive opioids during the postoperative period.
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Throughout the United States, the chronic use of opioids continues to be a substantial burden to the healthcare system in terms of morbidity, mortality, and economic costs. Studies show that the U.S. has seen a significant increase in the number of opioid-related overdoses and deaths in recent years. To reduce the incidence of chronic opioid use, researchers have identified some risk factors that may increase risks for prolonged use of these medications. Several studies have also suggested that surgery may be a risk factor for chronic opioid use.

Most of the studies examining prolonged opioid use in the surgery setting have been conducted in patients who have already been using these drugs and among those undergoing operations that are expected require opioids due to the expected pain resulting from the procedures. However, research is lacking on the incidence and risk factors for chronic opioid use among opioid-naive patients undergoing less painful procedures.

Characterizing Risk

For a retrospective analysis published in JAMA Internal Medicine, Eric C. Sun, MD, PhD, and colleagues used administrative health claims data to look at the incidence of chronic opioid use among opioid-naive patients within their first year after undergoing one of common 11 surgical procedures. These patients were then compared with non-surgical patients. The researchers also tested for several possible risk factors for chronic opioid use among surgical patients, including age, sex, history of alcohol or drug abuse, history of depression, and preoperative use of benzodiazepines, antipsychotics, and antidepressants.

The operations assessed in the study included several that do not typically produce long-term pain. The 11 procedures assessed were total knee arthroplasty, total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery, cataract surgery, transurethral prostate resection, and simple mastectomy.

In total, the study compared roughly 642,000 opioid-naive surgical patients with 18 million opioid-naive non-surgical patients. Chronic opioid use among surgical patients was defined as having filled 10 or more prescriptions or more than 120 days’ worth of supply of an opioid in the first year after surgery, excluding the first 90 postoperative days.

Wide Ranging Results

According to the study, the incidence of chronic opioid use in the first preoperative year among the surgical patients ranged widely, from as low as 0.12% for those receiving a cesarean delivery to as high as 1.41% for patients undergoing total knee arthroplasty. With the exception of cataract surgery, laparoscopic appendectomy, functional endoscopic sinus surgery, and transurethral prostate resection, all of the surgeries were associated with an increased risk of chronic opioid use when compared with the control group of nonsurgical patients. “Overall, the risk of chronic opioid use in surgery patients who haven’t been using these medications was relatively low, but the findings provide clinicians with information about which patients may be at higher risk,” says Dr. Sun.

Several factors were associated with chronic opioid use among surgical patients in the study. These included male sex, age older than 50, and a preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use (Table). It is possible that chronic opioid use with the first year of surgery occurs because the operation may unmask a patient’s susceptibility toward long-term opioid use. “Surgery patients are always at risk for postoperative pain, but it’s important to remember that pain is a subjective experience influenced by many psychological and behavioral factors,” Dr. Sun says. He adds that severe acute postoperative pain can also increase risks for chronic pain, which in turn may raise risks for chronic opioid use after surgery.

Significant Implications

“Our results shouldn’t be taken as advocating that patients forgo surgery due to concerns for chronic opioid use,” says Dr. Sun. “Instead, physicians and surgeons should monitor opioid use closely during the postoperative period.” He notes that many professional societies and associations have developed tools and checklists to help surgeons identify who may be at risk for opioid abuse or misuse.

Dr. Sun says it may behoove surgeons to provide surgical patients different pain management techniques, such as multimodal analgesia and regional anesthesia, if they are at higher risk for chronic opioid use. “In addition to reducing risks for opioid use and opioid-related adverse events, these strategies may improve other perioperative outcomes, such as mortality, complication rates, and length of stay,” he says. The authors of the study also recommend using preoperative and postoperative interventions in at-risk patients, such as evidence-based psycho-behavioral pain management skills.

More research is needed to determine if the results of the study apply to other surgical procedures and patient populations. “As more data are collected and we learn more about at-risk populations,” Dr. Sun says, “we may be able to use this information to find effective interventions that can be given during the postoperative period to reduce the risk of chronic opioid use.”

Readings & Resources (click to view)

Sun EC, Damall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naïve patients in the postoperative period. JAMA Intern Med. 2016 Jul 11 [Epub ahead of print]. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=2532789.

Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492.

Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician. 2012;15(suppl):ES67-ES92.

Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251.

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