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Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial.

ABSTRACT: Background:Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use. Methods:In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18-75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively. Results:Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87-1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68-0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40-0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39-0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80-0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89-1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06-1.77; P=0.016). Conclusion:Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes.

SUBMITTER: Hah JM

PROVIDER: S-EPMC7680674 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial.

Hah Jennifer M JM Hilmoe Heather H Schmidt Peter P McCue Rebecca R Trafton Jodie J Clay Debra D Sharifzadeh Yasamin Y Ruchelli Gabriela G Hernandez Boussard Tina T Goodman Stuart S Huddleston James J Maloney William J WJ Dirbas Frederick M FM Shrager Joseph J Costouros John G JG Curtin Catherine C Mackey Sean C SC Carroll Ian I

Journal of pain research 20201118

<h4>Background</h4>Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use.<h4>Methods</h4>In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18-75 years, undergoing diver ...[more]

PMID: 33239904

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Project description:Importance:Guidelines recommend using gabapentin to decrease postoperative pain and opioid use, but significant variation exists in clinical practice. Objective:To determine the effect of perioperative gabapentin on remote postoperative time to pain resolution and opioid cessation. Design, Setting, and Participants:A randomized, double-blind, placebo-controlled trial of perioperative gabapentin was conducted at a single-center, tertiary referral teaching hospital. A total of 1805 patients aged 18 to 75 years scheduled for surgery (thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, and shoulder arthroscopy) were screened. Participants were enrolled from May 25, 2010, to July 25, 2014, and followed up for 2 years postoperatively. Intention-to-treat analysis was used in evaluation of the findings. Interventions:Gabapentin, 1200 mg, preoperatively and 600 mg, 3 times a day postoperatively or active placebo (lorazepam, 0.5 mg) preoperatively followed by inactive placebo postoperatively for 72 hours. Main Outcomes and Measures:Primary outcome was time to pain resolution (5 consecutive reports of 0 of 10 possible levels of average pain at the surgical site on the numeric rating scale of pain). Secondary outcomes were time to opioid cessation (5 consecutive reports of no opioid use) and the proportion of participants with continued pain or opioid use at 6 months and 1 year. Results:Of 1805 patients screened for enrollment, 1383 were excluded, including 926 who did not meet inclusion criteria and 273 who declined to participate. Overall, 8% of patients randomized were lost to follow-up. A total of 202 patients were randomized to active placebo and 208 patients were randomized to gabapentin in the intention-to-treat analysis (mean [SD] age, 56.7 [11.7] years; 256 (62.4%) women and 154 (37.6%) men). Baseline characteristics of the groups were similar. Perioperative gabapentin did not affect time to pain cessation (hazard ratio [HR], 1.04; 95% CI, 0.82-1.33; P = .73) in the intention-to-treat analysis. However, participants receiving gabapentin had a 24% increase in the rate of opioid cessation after surgery (HR, 1.24; 95% CI, 1.00-1.54; P = .05). No significant differences were noted in the number of adverse events as well as the rate of medication discontinuation due to sedation or dizziness (placebo, 42 of 202 [20.8%]; gabapentin, 52 of 208 [25.0%]). Conclusions and Relevance:Perioperative administration of gabapentin had no effect on postoperative pain resolution, but it had a modest effect on promoting opioid cessation after surgery. The routine use of perioperative gabapentin may be warranted to promote opioid cessation and prevent chronic opioid use. Optimal dosing and timing of perioperative gabapentin in the context of specific operations to decrease opioid use should be addressed in further research. Trial Registration:clinicaltrials.gov Identifier: NCT01067144.

Project description:OBJECTIVE:We characterized patterns of preoperative opioid use in patients undergoing elective surgery to identify the relationship between preoperative use and subsequent opioid fill after surgery. BACKGROUND:Preoperative opioid use is common, and varies by dose, recency, duration, and continuity of fills. To date, there is little evidence to guide postoperative prescribing need based on prior opioid use. METHODS:We analyzed claims data from Clinformatics DataMart Database for patients aged 18 to 64 years undergoing major and minor surgery between 2008 and 2015. Preoperative use was defined as any opioid prescription filled in the year before surgery. We used cluster analysis to group patients by the dose, recency, duration, and continuity of use. Our primary outcome was second postoperative fill within 30 postoperative days. Our primary explanatory variable was opioid use group. We used logistic regression to examine likelihood of second fill by opioid use group. RESULTS:Out of 267,252 patients, 102,748 (38%) filled an opioid prescription in the 12 months before surgery. Cluster analysis yielded 6 groups of preoperative opioid use, ranging from minimal (27.6%) to intermittent (7.7%) to chronic use (2.7%). Preoperative opioid use was the most influential predictor of second fill, with larger effect sizes than other factors even for patients with minimal or intermittent opioid use. Increasing preoperative use was associated with risk-adjusted likelihood of requiring a second opioid fill compared with naive patients [minimal use: odds ratio (OR) 1.49, 95% confidence interval (95% CI) 1.45-1.53; recent intermittent use: OR 6.51, 95% CI 6.16-6.88; high chronic use: OR 60.79, 95% CI 27.81-132.92, all P values <0.001). CONCLUSION:Preoperative opioid use is common among patients who undergo elective surgery. Although the majority of patients infrequently fill opioids before surgery, even minimal use increases the probability of needing additional postoperative prescriptions in the 30 days after surgery when compared with opioid-naive patients. Going forward, identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery.

Dataset Information

Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial.

Publications

Preoperative Factors Associated with Remote Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: Post Hoc Analysis of a Perioperative Gabapentin Trial.

Similar Datasets

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