New research suggests more than one in five "opioid-naïve" patients continue to use the pain medication three months after having a procedure, underscoring the often-overlooked role surgery plays in the opioid epidemic. Presented at the ANESTHESIOLOGY 2021 annual meeting, the study found smokers and people with bipolar disorder, depression or pulmonary hypertension are at the highest risk.
The researchers note the results reflect a much higher incidence of persistent opioid use than expected among opioid-naïve patients (those who did not have an opioid prescription filled in the previous year). For many patients, surgery is the first time they have used opioids, which are often prescribed for the management of post-surgical pain. While opioids are effective, they are highly addictive and patients may not realize that they are misusing them, which can lead to an accidental overdose.
"The more than 100 million surgeries in the U.S. every year create an unintended and alarming gateway to long-term opioid use," said Gia Pittet, Au.D., Ph.D., lead author of the study and visiting graduate researcher for anesthesiology and perioperative medicine at the University of California, Los Angeles. "Clearly the management of opioid administration during the postoperative period needs to extend well beyond the hospital stay, with better transfer of care to the primary care physician. Additionally, our findings identify which patients would most benefit from effective preoperative consultation and should be followed especially carefully after surgery."
Researchers analyzed the records of 13,970 opioid-naïve adults who had surgery at UCLA hospitals from 2013-2019. In the study, opioid-naïve patients were those who had not filled an opioid prescription 31 days to one year before surgery (patients often are prescribed opioids in advance so they are available immediately after the surgery). Researchers found that 21.2% of patients refilled their opioid prescription three months to one year after the procedure. Unless they have cancer or had chronic pain before surgery, very few patients should still need opioids three months after surgery, the researchers note.
Analyzing 46 potential risk factors, researchers determined a wide variety of patients were still using opioids after three months. The top four risk factors identified, which were modifiable (meaning there were opportunities to address them), were: smoking, bipolar disorder, depression, and pulmonary hypertension (high blood pressure in the lungs). While patient-related factors are important, this study enabled researchers to look across the entire invasive surgery population. They found that procedures with cardiac and podiatry surgical providers and patients who had cataract surgery were at an increased risk of persistent opioid use.
"To reduce the likelihood of ongoing opioid use, physician anesthesiologists should use the preoperative assessment to identify patients at highest risk for persistent use," said Dr. Pittet. "Before they have surgery, patients who smoke should be encouraged to quit, those with pulmonary hypertension should see a doctor to help them get the condition under control and patients with bipolar disorder or depression may require a preoperative adjustment of their medications."
Additionally, patients should receive counseling about the safe use of opioids and be offered alternative pain management choices, such as limited or non-opioid multimodal treatment, and be monitored frequently and closely while they are taking opioids.
The Centers for Disease Control and Prevention (CDC) reported there were 94,000 drug overdose deaths in 2020, nearly 30% more than the previous year. While the CDC notes synthetic opioids (primarily illicitly manufactured fentanyl) appear to be the main reason for the increase, persistent opioid use after surgery can play a role.