R. A. Mann1, D. P. Marcusa1, D. C. Cron1, A. K. Rzepecki1, B. R. Fillinger1, L. Zhong2, M. J. Englesbe3, J. F. Waljee2 1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Section Of Plastic Surgery,Ann Arbor, MI, USA 3University Of Michigan,Section Of Transplantation Surgery,Ann Arbor, MI, USA
Introduction: In the United States, opioid misuse is accelerating, leading to excess morbidity and mortality. Furthermore, recent studies have suggested opioids are immunosuppressive, potentially resulting in chemoresistance among cancer patients. Opioid analgesics are commonly prescribed following surgery, but few guidelines exist regarding their use. Therefore, the purpose of this study was to examine the patient factors related to prolonged opioid use among a cohort of breast cancer patients undergoing breast reconstruction.
Methods: We identified 25,044 women who underwent immediate breast reconstruction between 1/2010-9/2013 using the Truven Health Marketscan® Research Databases, which collect insurance claims data from approximately 50 million individuals in the United States. We specifically examined the effect of patient demographics, comorbidities, co-existing mood disorders, preoperative opioid and benzodiazepine use on postoperative opioid use, controlling for procedure type (autologous vs. prosthesis-based reconstruction) and complications. We used multivariate logistic regression to assess the effects of each predictor on the probability of filling an opioid prescription a) within 6 weeks following surgery, and b) within 3 to 4 months following surgery.
Results: In this cohort, 66% of patients filled opioid prescriptions postoperatively, and 28% continued to fill opioid prescriptions 3 months following the reconstruction. Immediately following surgery, patients who had previously used opioids or benozodiazepines were more likely to fill opioid prescriptions ([OR]: 1.39, p<0.01; OR: 1.77, p<0.01). Opioid use declined with age (44-54 years: OR: 0.74, p<0.01; 55-64 years: OR: 0.66, p<0.01; 65 years and older: OR: 0.5, p<0.01). Protectors against prolonged use included autologous free perforator flap reconstruction (OR: 0.76, p<0.01). Predictors of continued opioid use at 3 months following surgery included preoperative opioid or opioid and benzodiazepine use (OR: 2.45, p<0.01; OR: 3.28, p<0.01), mood disorders (anxiety: OR: 1.20, p<0.01; depression: OR: 1.43, p<0.01), and substance abuse (OR: 1.42, p<0.01).
Conclusion: Opioid use is common following breast reconstruction, and up to 17% of all patients continue to use opioids beyond 90 days postop. Patients with pre-existing mood disorders and those who have previous exposure to opioid and benzodiazepine medications are particularly at risk of prolonged opioid use. Strategies to curb the overutilization of opioid analgesics should focus on identifying vulnerable patients and targeting additional preoperative counseling, alternative pain management techniques, and greater pain surveillance in the postoperative period.
