Anesthesia in the News
  • More than 1 in 5 Opioid-naïve Patients Persistently Use Opioids 3 Months after Surgery

    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.

    New research from the University of California in Los Angeles (UCLA) suggests more than 1 in 5 “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 recent Anesthesiology 2021 conference, the researchers note the results reflect a much higher incidence of persistent opioid use than expected among opioid-naïve patients, defined as those patients who had not had an opioid prescription filled in the previous year.

    The special risk of the new user

    For many patients, opioids prescribed for the management of post-surgical pain surgery represent their first usage of the medications.  While effective, opioids are highly addictive and patients may not realize that they are misusing them, which can lead to an accidental overdose.

    In the study, researchers analyzed the records of 13,970 opioid-naïve adults who had surgery at UCLA hospitals from 2013-2019.  Opioid-naïve patients were defined as those who had not filled an opioid prescription 31 days to one year before surgery.

    The authors developed a novel algorithm to merge the UCLA surgical cohort with the California state narcotics data to create a complete prescription catch approach for narcotic refills beyond the UCLA health system within the state of California.  Different statistical modeling methods including data modeling and algorithmic modeling were employed, and their performance was compared to find the best performing model.

    Over 21% refilled

    The 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, the researchers note, very few patients should still need opioids three months after surgery.

    The researchers analyzed 46 potential risk factors for persistent opioid use.  The top four risk-factors identified were all modifiable:  smoking, bipolar disorder, depression, and pulmonary hypertension.  Further, smoking proved to be a key predictor of new persistent postoperative opioid use.

    While patient-related factors are important, this study also 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.

    According to the authors, the identification of these significant risk factors can help to assist providers in their decision to refer the patients for additional medical management, provide patient educational counseling, and alter perioperative care choices, such as a limited or nonopioid multimodal analgesia in the perioperative period.

    Stopping at the start

    To reduce the likelihood of ongoing opioid use, anesthesiology providers “should use the preoperative assessment to identify patients at highest risk for persistent use,” advised Gia Pittet, AuD, PhD, visiting graduate researcher for anesthesiology and perioperative medicine at UCLA and lead author of the study.

    “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 post-discharge window

    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, the authors conclude.  In addition to identifying which patients would most benefit from effective preoperative consultation, the study also highlights those patients at special potential risk who should be followed especially carefully after surgery and by whom.

    “Hospitals should follow patients and measure continuing opioid use at a longer duration (90+ days), instead of several days or weeks past surgery.  Primary care physicians need to be included in this longer-term adherence monitoring effort.”

    “The more than 100 million surgeries in the U.S. every year create an unintended and alarming gateway to long-term opioid use,” concludes Pittet.  “Understanding who to target for an alternative care pathway could potentially prevent any opioid abuse from occurring, and this would have a huge downstream societal and economic consequence.”

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