P. Cavallaro1, A. Fields2, R. Bleday2, H. Kaafarani1, Y. Yao1, K. F. Ahmed1, T. Sequist1, M. Rubin1, L. Bordeianou1 1Massachusetts General Hospital,General Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Boston, MA, USA
Introduction: Nearly 42,000 people died from opioid overdose and an estimated 40% of overdose deaths involved a prescription opioid in 2016 alone. However, the relationship between postoperative inpatient opioid use and the subsequent risk of long-term opioid abuse remains unknown, with studies focusing primarily on opioid prescriptions at time of discharge. We therefore aimed to evaluate the relationship between inpatient opioid use and ultimate prolonged opioid use (POU) in patients undergoing colorectal surgery.
Methods: We merged pharmacy records and the prospectively maintained ACS-NSQIP data on surgical outcomes of patients undergoing colectomy from June 2015 to October 2017 across 5 institutions (2 academic, 3 community) participating in a regional Colorectal Surgery Collaborative. Narcotic administration was converted into Morphine Milligram Equivalents (MMEs). Patients using patient-controlled analgesia were excluded. POU was the primary outcome and was defined as any new opioid prescriptions between 90 and 180 days post-operatively. We compared patient demographics, surgical indications, comorbidities, and postoperative complications, daily MME administration and total inpatient MMEs.
Results: 940 colectomy patients were included in the study (52% female, 43.3% opioid naive, mean age 62.2 years old). 99 patients (10.4%) had POU. On univariate analysis, POU patients had higher ASA (ASA > 3 in 61% vs 44%, p=0.002) and were less opioid naive (23% vs 46%, p<0.001). These patients had longer lengths of stay, more readmissions, and more post-operative complications (P<0.05). POU patients also had higher rates of stomas (p<0.05). POU patients had increased rates of cumulative MMEs administered throughout their more complex hospitalization, even though their daily dosages were similar to non PRU patients (50+/-44 vs 73+/-704, p=0.7). In multivariable analysis, only cumulative use of narcotics —not overall complications or length of stay — was predictive of POU (Top quartile OR 2.0, 95% CI 1.2-3.2; p=0.005). Previous opioid use within the last year was also and independent predictor of POU (OR 2.6, 95% CI 1.6-4.3; p<0.001).
Conclusion: Prolonged narcotic use appears to be associated with previous narcotic exposure and the cumulative does of narcotics administered during the post-operative inpatient hospitalization, and not by the complexity of the surgical procedure or by surgical complications. This underscores the importance of minimizing opioid use through the entire peri-operative course, especially in patients with prior opioid use, post-operative complications, and protracted hospital courses. It also suggests the need for development of longer-lasting postoperative narcotic-sparing strategies, beyond the current ERAS efforts, that are mostly focused on the first 24-48 hours after surgery.