J. S. Lee1, H. M. Hu1, D. C. Cron1, C. M. Brummett2, M. J. Englesbe1, J. F. Waljee1 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Anesthesiology,Ann Arbor, MI, USA
Introduction:
Opioid misuse and abuse is a national public health crisis with an estimated 44 deaths each day from prescription opioid overdose. Moreover, chronic opioid use confers a disproportionately high risk of morbidity, mortality, and increased healthcare expenditures. Although 40% of opioid prescriptions are written for postoperative pain relief, the risk of transitioning to chronic use is not well understood. In this study, we sought to define long-term trends in opioid use following surgery.
Methods:
Using a national dataset of employer-based insurance claims, we identified U.S. adults age 18 – 64 years old undergoing major (bariatric surgery, colectomy, incisional hernia repair, reflux surgery, hysterectomy) and minor elective surgery (varicose vein removal, laparoscopic cholecystectomy/appendectomy, hemorrhoidectomy, transurethral prostate surgery, thyroidectomy, parathyroidectomy, carpal tunnel release) from January 2013 – December 2014 (n=57,760). Opioid prescriptions were obtained from pharmacy claims and converted to oral morphine equivalents (OME) for comparison. Patients were stratified into 5 groups based on preoperative opioid use: naive, intermittent, and chronic (high, medium, low) opioid users. Naive patients with new persistent opioid use 90 days after surgery were analyzed as a separate group. Primary outcomes were daily opioid dose and concurrent benzodiazepine use, given its strong association with opioid overdose fatalities. Outcomes were evaluated at 30-day intervals from 180 days before surgery to 180 days after surgery, and compared using a mixed model approach.
Results:
58.9% of patients were opioid naive with no persistent postoperative opioid use, 3.8% developed new persistent opioid use, 29.1% were intermittent users, and 8.2% were chronic users. All groups were alike in demographics and case mix, but had significantly different trends for the primary outcomes (p<0.0001). Chronic and intermittent opioid users returned to baseline levels of opioid use following surgery (Figure 1). In contrast, patients with new persistent opioid use continued taking high doses 6 months after surgery without decline, equivalent to 6 tablets/day of hydrocodone/acetaminophen 5/325, and at similar doses to chronic users. They also had escalating rates of concurrent benzodiazepine use, increasing from 2.3% to 5.2% six months after surgery.
Conclusion:
New persistent opioid use continues long after surgery with maintenance of high daily doses and rising rates of concurrent benzodiazepine use. Given the substantial morbidity and mortality associated with chronic opioid exposure, it is critical to identify patients at risk of developing postoperative opioid dependence and target interventions to mitigate persistent use.
