Persistent Postoperative Opioid Use: A Systematic Literature Search of Definitions and Population-based Cohort Study.
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ABSTRACT: Background
While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events.Methods
The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery.Results
Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00.Conclusions
The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures.
SUBMITTER: Jivraj NK
PROVIDER: S-EPMC8202398 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:This retrospective cohort study on adults undergoing colectomy from 2010 to 2019 used linked primary (Clinical Practice Research Datalink), and secondary (Hospital Episode Statistics) care data to determine the prevalence of persistent postoperative opioid use following colectomy, stratified by pre-admission opioid exposure, and identify associated predictors. Based on pre-admission opioid exposure, patients were categorised as opioid-naïve, currently exposed (opioid prescription 0-6 months before admission) and previously exposed (opioid prescription within 7-12 months before admission). Persistent postoperative opioid use was defined as requiring an opioid prescription within 90 days of discharge, along with one or more opioid prescriptions 91-180 days after hospital discharge. Multivariable logistic regression analyses were conducted to obtain odds ratios for predictors of persistent postoperative opioid use. Among the 93,262 patients, 15,081 (16.2%) were issued at least one opioid prescription within 90 days of discharge. Of these, 6791 (45.0%) were opioid-naïve, 7528 (49.9%) were currently exposed and 762 (5.0%) were previously exposed. From the whole cohort, 7540 (8.1%) developed persistent postoperative opioid use. Patients with pre-operative opioid exposure had the highest persistent use: 5317 (40.4%) from the currently exposed group; 305 (9.8%) from the previously exposed group; and 1918 (2.5%) from the opioid-naïve group. The odds of developing persistent opioid use were higher among individuals who used long-acting opioid formulations in the 180 days before colectomy than those who used short-acting formulations (odds ratio 3.41 (95%CI 3.07-3.77)). Predictors of persistent opioid use included: previous opioid exposure; high deprivation index; multiple comorbidities; use of long-acting opioids; white race; and open surgery. Minimally invasive surgical approaches were associated with lower odds of persistent opioid use and may represent a modifiable risk factor.
| S-EPMC10953341 | biostudies-literature
Project description:ObjectiveEvaluate the association between postoperative opioid prescribing and new persistent opioid use.Summary background dataOpioid-nave patients who develop new persistent opioid use after surgery are at increased risk of opioid-related morbidity and mortality. However, the extent to which postoperative opioid prescribing is associated with persistent postoperative opioid use is unclear.MethodsRetrospective study of opioid-naïve adults undergoing surgery in Michigan from 1/1/2017 to 10/31/2019. Postoperative opioid prescriptions were identified using a statewide clinical registry and prescription fills were identified using Michigan's prescription drug monitoring program. The primary outcome was new persistent opioid use, defined as filling at least 1 opioid prescription between post-discharge days 4 to 90 and filling at least 1 opioid prescription between post-discharge days 91 to 180.ResultsA total of 37,654 patients underwent surgery with a mean age of 52.2 (16.7) years and 20,923 (55.6%) female patients. A total of 31,920 (84.8%) patients were prescribed opioids at discharge. Six hundred twenty-two (1.7%) patients developed new persistent opioid use after surgery. Being prescribed an opioid at discharge was not associated with new persistent opioid use [adjusted odds ratio (aOR) 0.88 (95% confidence interval (CI) 0.71-1.09)]. However, among patients prescribed an opioid, patients prescribed the second largest [12 (interquartile range (IQR) 3) pills] and largest [20 (IQR 7) pills] quartiles of prescription size had higher odds of new persistent opioid use compared to patients prescribed the smallest quartile [7 (IQR 1) pills] of prescription size [aOR 1.39 (95% CI 1.04-1.86) andaOR 1.97 (95% CI 1.442.70), respectively].ConclusionsIn a cohort of opioid-naïve patients undergoing common surgical procedures, the risk of new persistent opioid use increased with the size of the prescription. This suggests that while opioid prescriptions in and of themselves may not place patients at risk of long-term opioid use, excessive prescribing does. Consequently, these findings support ongoing efforts to mitigate excessive opioid prescribing after surgery to reduce opioid-related harms.
| S-EPMC10537242 | biostudies-literature
Project description:DisclaimerIn an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.PurposeTo identify the proportion of patients with continued opioid use after total hip or knee arthroplasty.MethodsThis systematic review and meta-analysis searched Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts for articles published from January 1, 2009, to May 26, 2021. The search terms (opioid, postoperative, hospital discharge, total hip or knee arthroplasty, and treatment duration) were based on 5 key concepts. We included studies of adults who underwent total hip or knee arthroplasty, with at least 3 months postoperative follow-up.ResultsThere were 30 studies included. Of these, 17 reported on outcomes of total hip arthroplasty and 19 reported on outcomes of total knee arthroplasty, with some reporting on outcomes of both procedures. In patients having total hip arthroplasty, rates of postoperative opioid use at various time points were as follows: at 3 months, 20% (95% CI, 13%-26%); at 6 months, 17% (95% CI, 12%-21%); at 9 months, 19% (95% CI, 13%-24%); and at 12 months, 16% (95% CI, 15%-16%). In patients who underwent total knee arthroplasty, rates of postoperative opioid use were as follows: at 3 months, 26% (95% CI, 19%-33%); at 6 months, 20% (95% CI, 17%-24%); at 9 months, 23% (95% CI, 17%-28%); and at 12 months, 21% (95% CI, 12%-29%). Opioid naïve patients were less likely to have continued postoperative opioid use than those who were opioid tolerant preoperatively.ConclusionOver 1 in 5 patients continued opioid use for longer than 3 months after total hip or knee arthroplasty. Clinicians should be aware of this trajectory of opioid consumption after surgery.
| S-EPMC8513405 | biostudies-literature
Project description:Introduction: Minimally invasive surgery offers reduced pain and opioid use postoperatively compared with open surgery, but large-scale comparative studies are lacking. We assessed the incidence of persistent opioid use after open and robot-assisted radical prostatectomy (RARP). Materials and Methods: We performed a retrospective claims database cohort study of opioid-naive (i.e., no opioid prescriptions 30-180 days before index surgery) adult males who underwent radical prostatectomy for prostate cancer from July 2013 to June 2017. For patients who filled a perioperative opioid prescription (30 days before to 14 days after surgery), we calculated the incidence of new persistent postoperative opioid use (?1 prescription 90-180 days after surgery). Multivariable logistic regression was performed to investigate the association between the surgical approach, patient risk factors, and persistent opioid use. Results: Twelve thousand two hundred seventy-eight radical prostatectomy patients filled an opioid prescription perioperatively (1510 [12%] open and 10,768 [88%] robot assisted). Of these, 846 (6.9%) patients continued to fill opioid prescription(s) 90 to 180 days after surgery. Patients undergoing RARP were 35% less likely to develop new persistent opioid use compared with those undergoing open radical prostatectomy (6.5% vs 9.7%; adjusted odds ratio 0.65; 95% confidence interval 0.54, 0.79). Other independent risk factors included living in the southern, western, or north central United States; preoperative comorbidity; and tobacco use. Conclusions: Approximately 6.9% of opioid-naive patients continued to fill opioid prescriptions 90 days after radical prostatectomy. The risk of persistent opioid use was significantly lower among patients undergoing a robot-assisted vs open approach. Further efforts are needed to develop postoperative opioid prescription protocols for patients undergoing radical prostatectomy.
| S-EPMC7194325 | biostudies-literature
Project description:PurposeOpioids are commonly prescribed for acute pain after surgery. However, it is unclear whether these prescriptions are usually modified to account for patient age and, in particular, opioid-related risks among older adults. We therefore sought to describe postoperative opioid prescriptions filled by opioid-naïve adults undergoing four common surgical procedures.MethodsThis retrospective cohort study used individually linked surgery and prescription opioid dispensing data from Ontario, Canada to create a population-based sample of 135 659 opioid-naïve adults who underwent one of four surgical procedures (laparoscopic cholecystectomy, laparoscopic appendectomy, knee meniscectomy, or breast excision) between 2013 and 2017. Patient age, in years, was categorized as 18 to 64, 65 to 69, 70 to 74, and 75 and over. Postoperative opioid prescriptions were identified as those filled on or within 6 days of surgical discharge date. For those who filled a prescription, we assessed the total morphine milligram equivalent (MME) dose, types of opioids, and any subsequent opioid prescriptions filled within 30 days of surgical discharge date. Results were presented stratified by surgical procedure.ResultsFor three of the four surgical procedures we assessed, the proportion of patients who filled a postoperative opioid prescription decreased with age (P < 0.001 for trend), and there was a small shift in the type of opioid (more codeine or tramadol and less oxycodone; P < 0.001 for trend). However, the total MME dose of the initial prescription(s) filled showed minimal age-related trends.ConclusionsThe proportion of opioid-naïve patients filling postoperative opioid prescriptions decreases with age. However, postoperative opioid prescription dosage is not typically different in older adults.
| S-EPMC7188586 | biostudies-literature
Project description:IntroductionOpioid use has increased globally for the management of chronic non-cancer-related pain. There are concerns regarding the misuse of opioids leading to persistent opioid use and subsequent hospitalisation and deaths in developed countries. Hospital admissions related to surgery or trauma have been identified as contributing to the increasing opioid use internationally. There are minimal data on persistent opioid use and opioid-related harm in New Zealand (NZ), and how hospital admission for surgery or trauma contributes to this. We aim to describe rates and identify predictors of persistent opioid use among opioid-naïve individuals following hospital discharge for surgery or trauma.Methods and analysisThis is a population-based, retrospective cohort study using linked data from national health administrative databases for opioid-naïve patients who have had surgery or trauma in NZ between January 2006 and December 2019. Linked data will be used to identify variables of interest including all types of hospital surgeries in NZ, all trauma hospital admissions, opioid dispensing, comorbidities and sociodemographic variables. The primary outcome of this study will be the prevalence of persistent opioid use. Secondary outcomes will include mortality, opioid-related harms and hospitalisation. We will compare the secondary outcomes between persistent and non-persistent opioid user groups. To compute rates, we will divide the total number of outcome events by total follow-up time. Multivariable logistic regression will be used to identify predictors of persistent opioid use. Multivariable Cox regression models will be used to estimate the risk of opioid-related harms and hospitalisation as well as all-cause mortality among the study cohort in a year following hospital discharge for surgery or trauma.Ethics and disseminationThis study has been approved by the Auckland Health Research Ethics Committee (AHREC- AH1159). Results will be reported in accordance with the Reporting of studies Conducted using Observational Routinely collected health data statement (RECORD).
| S-EPMC7817825 | biostudies-literature
Project description:ImportanceAlthough the development of persistent opioid use after surgical procedures has garnered much attention in recent years, large-scale studies characterizing patterns of persistent opioid use among patients undergoing plastic and reconstructive surgery procedures are lacking.ObjectiveTo assess the prevalence of immediate and long-term postoperative opioid use after plastic and reconstructive surgery procedures.Design, setting, and participantsIn this population-based cohort study, patients who underwent 5 classes of plastic and reconstructive procedures (nasal, eye, breast, abdomen, and soft tissue reconstruction) between January 1, 2007, and December 31, 2015, were identified using IBM MarketScan Commercial and Medicare Supplemental research databases. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year preoperatively and postoperatively, had a second anesthesia event within 1 year postoperatively, and filled an opioid prescription within the year prior to surgery.Main outcomes and measuresAnalgesic prescription patterns in the immediate postoperative period. The primary outcome was rates of persistent opioid use (opioid prescriptions filled 90-180 days postoperatively). The secondary outcome was rates of prolonged opioid use (opioid prescriptions filled 90-180 days postoperatively and again 181-365 days postoperatively). Explanatory variables included patient demographics, procedure type, and relevant comorbidities.ResultsOf the 466 677 patients who met inclusion criteria, 96 397 (45.3%) were men, and the mean (SD) age was 46.8 (17.7) years. Furthermore, 212 387 (54.6%) of the patients filled prescriptions for postoperative analgesics, with 212 387 (91.5%) of analgesic prescriptions filled being for opioids. Persistent opioid use occurred in 30 865 (6.6%) patients (5.1%-13.5% across procedure classes), while prolonged opioid use occurred in 10 487 (2.3%) patients (1.7%-5.6% across procedure classes). Patients who filled prescriptions for opioids in the perioperative period were significantly more likely to exhibit persistent (odds ratio [OR], 2.87; 95% CI, 2.80-2.94) and prolonged (OR, 2.90; 95% CI, 2.77-3.02) opioid use than those who did not fill perioperative opioid prescriptions, with the greatest odds for persistent use found in patients who underwent breast (OR, 4.36; 95% CI, 4.10-4.63) and nasal (OR, 3.51; 95% CI, 3.30-3.73) procedures. On multivariable logistic regression analysis, independent risk factors for persistent and prolonged opioid use included perioperative opioid use, procedure type, and prior-year mental health (depression and anxiety) and substance abuse diagnoses.Conclusions and relevanceGiven the significant risk of persistent opioid use after plastic and reconstructive procedures, it is imperative to develop best practices guidelines for postoperative opioid prescription practices in this population.Level of evidenceNA.
| S-EPMC6583832 | biostudies-literature
Project description:ImportanceVitamin D deficiency is associated with chronic pain syndromes and higher opioid use among cancer patients, but its association with opioid use among opioid-naïve subjects following a major surgical procedure with acute pain has not been explored.ObjectiveTo determine the association between serum 25-hydroxyvitamin D (25(OH)D) levels, opioid use, and opioid use disorder.MethodsWe identified commercially insured subjects aged 18-64 years with available perioperative serum 25-hydroxyvitamin D (25D) levels who underwent one of nine major surgical procedures in 2000-2014. Primary outcomes were dose and duration of opioid use measured using pharmacy claims. Secondary outcome was opioid use disorder captured using diagnosis codes. Multivariable negative binomial models with generalized estimating equations were performed examining the association between 25D levels and postoperative opioid use measures, adjusting for age, sex, race/ethnicity, Charlson score, education, income, latitude, and season of blood draw. Adjusted Cox regression was used to examine the association with opioid use disorder.ResultsAmong 5446 subjects, serum 25(OH)D was sufficient (≥ 20 ng/mL) among 4349 (79.9%) subjects, whereas 837 (15.4%) had insufficient (12 to < 20 ng/mL) and 260 (4.8%) had deficient (< 12 ng/mL) levels. On multivariable analysis, as compared with subjects with sufficient 25(OH)D levels, subjects with deficient 25(OH)D levels had 1.7 more days (95% CI 0.76, 2.58) of opioid use per year and had 98.7 higher morphine milligram equivalent dose (95% CI 55.7, 141.8) per year. Among 11,713 study cohort, subjects with deficient 25(OH)D levels were more likely to be diagnosed with opioid use disorders (HR 2.41; 95% CI 1.05, 5.52).ConclusionPatients undergoing common surgical procedures with deficient 25D levels are more likely to have higher opioid use and an increased risk of opioid use disorder compared to those with sufficient levels. Serum 25D levels may serve as a biomarker to identify subjects at increased risk of opioid misuse.
| S-EPMC7459073 | biostudies-literature
Project description:BackgroundOpioid use has increased dramatically in North America. The safety of opioids in pregnancy is uncertain, but they are associated with several fetal abnormalities and contribute to rising rates of neonatal abstinence syndrome. We examined opioid use before and during pregnancy in a complete population-based cohort.MethodsWe examined opioid use in a cohort of all pregnant women in Manitoba, Canada, from 2001 to 2013. Opioid use was defined by prescriptions for opioids, converted to oral morphine equivalents (MEQ), during the 3 months before pregnancy and for each trimester. Given that the exposure per person may vary (because not all women complete all time periods), we determined a weighted number of pregnancies in each period.ResultsDuring the study period, 174 848 completed pregnancies were eligible for analysis (173 680 live births and 1168 stillbirths and intrauterine deaths), which represented a weighted value of 175?174 pregnancies. Among these pregnancies, 6.7% of the women filled opioid prescriptions in the 3 months before pregnancy. Use declined to 4.2% during the first trimester and further declined to 3.0% and 2.9% in the second and third trimesters, respectively. Over the study period, there was a modest increase in opioid use overall (from 7.3% to 7.7%). MEQ did not decline during pregnancy, and the mean MEQ increased significantly over the study period (from 284 mg to 1218 mg). Prescriptions for codeine were filled by 96.9% of the users, accounting for 66.2% of MEQ.InterpretationAlthough many of the women using opioids before pregnancy discontinued or reduced use of these drugs during pregnancy, the volume of opioids consumed by those who continued opioid use did not decline during pregnancy. The increasing dosage and increased use of higher-potency opioids by pregnant women highlights the need for continued evaluation of and education about the benefits and risks of this practice.
| S-EPMC5498419 | biostudies-literature
Project description:ObjectiveTo evaluate outpatient opioid dispensing and the incidence of persistent opioid use after ectopic pregnancy.MethodsThis cohort study used U.S. employer-based claims data to identify opioid-naïve individuals experiencing ectopic pregnancy from November 1, 2008, to September 30, 2015. Treatment was categorized as surgical, medical (using methotrexate), or unknown. New opioid prescriptions were defined as prescriptions filled from 1 week before to 1 week after an ectopic pregnancy treatment. For those who filled a new opioid prescription, we calculated the incidence and risk factors for persistent opioid use, defined as having filled at least one opioid prescription both from 8 to 90 days after treatment and from 91 to 365 days after treatment.ResultsOf the 15,338 individuals in our study, 7,047 (45.9%, 95% CI 45.2-46.7%) filled an opioid prescription at the time of treatment, of whom 4.1% (95% CI 3.6-4.6%) developed persistent opioid use. The risk of persistent opioid use was lower among those who had surgical compared with medical treatment (3.7% and 6.8%, respectively; relative risk [RR] 0.54, 95% CI 0.38-0.77). Variables most strongly associated with persistent opioid use were a history of benzodiazepine use (RR 1.99; 95% CI 1.43-2.78; adjusted relative risk [aRR] 1.57, 95% CI 1.11-2.22), antidepressant use (RR 1.91, 95% CI 1.45-2.53; aRR 1.53, 95% CI 1.08-2.18), and a pre-existing pain disorder (RR 1.58, 95% CI 1.26-1.99; aRR 1.47, 95% CI 1.16-1.85) in the year before treatment.ConclusionNew opioid use is common after an ectopic pregnancy; approximately 4% of those with new opioid use develop persistent opioid use, with the rate higher in those treated medically. New pain-management guidelines need to be developed to prevent persistent opioid use after ectopic pregnancy.
| S-EPMC7962340 | biostudies-literature