Patients undergoing cardiac and lung surgeries have a higher risk for new persistent opioid use that can lead to dependence compared with other surgical patients, and the risk is strongly associated with the number of opioid pills prescribed, researchers found from a Medicare claims analysis.
A total of 15.7% of formerly opioid-naive patients undergoing lung surgery and 12.5% having cardiac surgery in the study conducted by University of Michigan Medicine researchers continued to use the oral prescription painkillers months after surgery.
The study by Alexander Brescia, MD, MSc, and colleagues found that prescription size was a strong predictor of persistent opioid use following cardiothoracic surgery, with patients prescribed the most pills -- the equivalent of more than 60 oral morphine pills -- nearly twice as likely to continue using opioids than those prescribed 27 or fewer pills (19.6% vs 10.4%).
Being prescribed opioids in the month prior to surgery was found to be the strongest modifiable risk factor for new persistent use, the team reported in . Importantly, however, the study did not have data on patients' pain severity prior to or following surgery, which could have helped explain why opioid use became persistent.
"It isn't really clear why patients are prescribed [new opioid] pain medications prior to surgery, but the practice has been linked to increased risk for persistent use in prior studies," Brescia told 51˶.
Earlier studies, he noted, have found that 3%-8% of previously opioid-naive general surgery patients are still taking the painkillers 3-6 months after surgery, which defines "new persistent use."
For example, a study by Brescia's team found that 14% of patients undergoing surgical resection for lung cancer had new persistent opioid use. No previous studies have examined new persistent opioid use among cardiac surgery patients.
Study Details
The new study included opioid-naive Medicare patients who underwent cardiothoracic surgeries from 2009 to 2015 and filled an opioid prescription from 30 days before surgery to 14 days after hospital discharge.
All patients were enrolled in Medicare for at least 12 months before surgery and 6 months after surgery, and new persistent use was defined as continued prescription fills for 3-6 months after surgery. Prescription size was reported in oral morphine equivalents ().
The study included data on 24,549 Medicare enrollees (average age of 71, 38% women, 85% white).
Overall, new persistent opioid use occurred among 12.8% of the patients.
When the researchers adjusted for known opioid dependence risk factors using multivariable regression, adjusted new persistent use was 19.6% (95% CI 18.7%- 20.4%) among patients prescribed more than 450 OME, compared with 10.4% (95% CI 9.9%-10.8%) among patients prescribed 200 OME or less (P<0.001).
In addition to prescription size and timing, other predictors of increased risk for new persistent use included the following:
- Female sex
- Younger age
- Black race
- Tobacco use
- Gastrointestinal complications
- Qualifying for Medicaid
- Disability status
- Having multiple comorbidities
- Drug and substance abuse
- Longer hospital stay post-surgery
New persistent opioid use among the postsurgical patients declined over the course of the study period, from 17% in 2009 to 7.1% in 2015 (P<0.001).
The researchers noted that this decline may be due to increased awareness among clinicians and patients about the addictive potential of opioid pain relievers.
Overall Message about Pain Has Changed
The message to patients prior to surgery has shifted, and patients are no longer told that they should never be in pain, Brescia explained: "The goal is to make sure that a patient's pain is managed and that they are comfortable. But that is very different from telling patients that they should never be in pain."
He added that much of the shift in prescribing practices has been driven by patients who are concerned about becoming addicted to opioid pain medications.
"Patients often tell us that they don't want as much medication as we are giving them," he said.
Brescia and study co-author Kiran Lagisetty, MD, told 51˶ that their analysis of heart surgery patients undergoing sternotomy found that patients often needed far fewer pain pills than prescribed.
"What we found is that most patients given oxycodone should probably be sent home with 0 to 25 pills," Brescia said. "That range reflects the finding that there are really three distinct groups of patients, distinguished by how much opioid they are receiving before leaving the hospital."
Patients whose pain was managed with little medication while hospitalized may need no opioids after discharge, while those requiring higher doses of opioids during hospitalization may need more, the researchers said.
Disclosures
Brescia is supported by the National Research Service Award postdoctoral fellowship. Other funding was provided by the Michigan Department of Health and Human Services.
No disclosures were reported.
Primary Source
The Annals of Thoracic Surgery
Brescia AA, et al "Impact of prescribing on new persistent opioid use after cardiothoracic surgery" Ann Thor Surg 2019; DOI: 10.1016/j.athoracsur.2019.06.019.