Pushing Back Against the Narrative of Persistent Opioid Use Following Surgery

There has been an established narrative for years indicating that opioid use throughout and following surgical procedures increases risk of long-term opioid use thereafter. In fact, because of this growing narrative, some surgical centers are attempting to become opioid-free, and are actually promoting the avoidance of perioperative opioids altogether.

What a load of hogwash!!

Not only have these associations been questioned by multiple groups and clinicians in the past, but there is now growing evidence that actually supports the exact opposite. Specifically, one recent study published in the Annals of Surgery found that opioid use throughout surgery had no significant bearing on chronic or long-term opioid use thereafter.

Let’s take a look at these narratives and the evidence that dismantles some of these barbaric strategies of perioperative pain control.

 

The Narrative: Opioid use during surgery causes persistent opioid use after

For the past several years, more and more review articles, guidelines, and editorials have highlighted and outlined seemingly correlated risks of pre-operative and post-operative opioid use, and the development of “persistent opioid use” OR “opioid use disorder” OR “opioid abuse”. What the heck is the difference between all these terms and is there actually a direct risk? Or, are there other factors involved?

 

Definitions of long-term opioid use:

To start, let’s differentiate some of the outcomes that “researchers” have evaluated as they relate to perioperative opioid use.

Persistent opioid use is defined as the use of opioids 90 days after surgery in preoperative opioid-naïve patients (though, even this changes study to study).  Of course, this is DRASTICALLY different than an actual diagnosis of opioid use disorder (which itself is commonly misdiagnosed). Opioid use disorder is a set of specific criteria defined by the DSM-V… Thus, OUD DOES NOT EQUAL an arbitrary definition of “persistent opioid use”. Opioid abuse is an even less defined and highly inappropriate term, realistically indicating “abuse or misuse” of any opioid. This could be an opioid prescribed to the patient, not prescribed, or somewhere in between. However, opioid abuse is not a clinical diagnosis itself, and more of a poor descriptor of someone using an opioid in a way other than prescribed (or not prescribed) by the practitioner.

Okay, now that we have definitions out of the way, let’s look at some review articles pushing this narrative that perioperative opioid use increases risk of these opioid use comorbidities.

 

Evidence pushing against use of perioperative opioids:

From a preoperative opioid use perspective, there have been some well-documented concerns. For example, in one cohort study of patients undergoing elective surgery, preoperative opioid use was associated with longer hospital stays, higher rates of 30-day readmissions, and increased healthcare expenditures. A smaller study showed that long-term opioid use prior to surgery was associated with increased risk of knee revision within the first year following total knee arthroplasty in veteran patients.

However, there could be several different reasons that these associations exist. Certainly, one could stem from the other side effects opioids may be associated with (immunosuppression, endocrine dysfunction, etc). In addition, one reason that never seems to be discussed is the fact that patients on chronic opioids prior to surgical procedures presumably already have chronic pain conditions they are suffering from. Thus, the surgery they are undergoing may not be directly related to the other chronic pain problems (therefore that surgery is not correcting the underlying cause in the first place). Those other chronic pain problems may also impact overall recovery, making it unattainable for patients after undergoing certain surgeries (often when strengthening is needed most). Certainly, behavioral health comorbidities is higher in those with chronic pain, thus surgery itself may play an underlying role of disrupting and exacerbating underlying mental health disorders contributing to risk. Finally, the operations themselves may be associated with worsened outcomes in these patients.

Well, what does any of this have to do with risk of opioid use after surgeries? After all, the ‘data’ shows that patients receiving an opioid prescription after a ‘short-stay’ surgery have a 44% increased risk of long-term opioid use. Plus, another trial showed that over 60% of patients receiving 90 days of continuous opioid therapy following surgery remain on opioids ‘years later’. Additionally, yet another study found prescribing of any opioid at hospital discharge following surgery to a previously opioid naïve patient was an independent risk factor for chronic opioid use 1 year after discharge.

Surely, this can’t be all hogwash? Can it?

The problem with all of this ‘data’ is that it’s inherently biased. For the most part, it shouldn’t come as a surprise to anyone that requiring opioids after surgery may actually indicate that the surgery itself was unsuccessful or created some type of chronic post-surgical pain. It doesn’t mean that using the opioid itself caused the patient to require opioids long-term thereafter, but could be a reflection of new underlying reasons from a pain perspective that the patient now requires an opioid.

We, in fact, know that surgery itself is an independent stimulus for chronic opioid use. So, should the answer be to never conduct surgeries in anyone because there is a risk for chronic PAIN SYNDROMES afterward (however small a risk that may be)?

Further, studies tend to be highly variable when assessing the criteria of persistent opioid use after surgery in general. Some studies that found rates of ‘new persistent opioid use’ between 5.9-6.5% in patients who underwent surgery who were previously opioid naïve, used a definition of ‘any opioid prescription filled between 90 and 180 days after the surgical procedure’. HUH? So, you’re saying that the opioid could have been filled for ANY pain condition, potentially unrelated to the surgery itself? Other, more well-designed studies, used definitions of chronic opioid use as 10 or more prescriptions, or more than 120 days’ supply of an opioid within the first year following surgery, excluding the first 90 days. Interestingly, that study in particular found much lower rates of chronic opioid use status post surgery, with the greatest incidence of chronic use being 1.41% following total knee arthroplasty.

Really makes you think about this ‘data’ in a different light, doesn’t it?

 

Recent evidence around prolonged opioid use following surgeries:

The buzzworthy research recently published in the Annals of Surgery adds to the growing evidence that dismantles much of the ‘established narrative’ as is detailed above regarding persistent opioid use after surgery. This trial was prospective in nature (compared to the VAST MAJORITY of evidence used in the past that has been retrospective in nature) and included a small cohort of opioid naïve surgical patients who were prescribed opioids at discharge following surgery. Only 15.3% of the patients filled opioid prescriptions between 3-12 months after the initial surgery. 51% of those patients filled an opioid prescription because of a NEW painful conditions, and 40% filled the opioid because they underwent an additional surgery. Only 6% of those patients filled the opioid because of pain related to the initial operation, and 2.3% filled because of chronic pain from recurrent cancer, a new medical condition, or a chronic abscess.

This study adds to evidence from a prospective study evaluating patients presenting to the emergency room who were discharged on prescription opioids for pain and followed for six months after. While it was another small cohort study, they found that only 1% (5 patients) met their criteria for persistent opioid use by the end of the follow up period, and 4 out of those 5 patients were still using opioids for pain in the affected body part six months after ER discharge. Further, a study published in JAMA Surgery just two days ago found that in 61,249 patients undergoing surgery, greater intraoperative opioid administration was associated with decreased new chronic pain diagnoses at 3 months, decreased opioid prescriptions at 30, 90, 180 days, and decreased new persistent opioid use. This may actually indicate that reducing opioid administration throughout surgery may increase incidence of post-op pain and opioid use.

All of this correlates with the fact that opioid ‘misuse’ rates actually remain substantially low in those undergoing surgical procedures. In fact, one study published in 2018 in the BMJ found a ‘misuse’ rate of just 0.6% in 568,000 opioid naïve patients prescribed opioids for acute and postoperative pain throughout the period of 2008-2016. Now, the study did show that longer duration of opioid therapy following surgeries was associated with increasing rates of opioid misuse, though this is a clear distinction from use of opioids in the perioperative setting itself!

 

The Bottom Line: Perioperative Opioid Use

When it comes to narratives around opioids, they seemingly never end. There is no doubt a multitude of risks when it comes to prescribing of any opioids, but particularly specific risks when they are used in perioperative settings. However, well-designed, prospective, controlled trials have consistently shown that perioperative opioid use (including post-operative use) does not lead to persistent opioid use solely as a result of opioid prescriptions given for the initial surgery. There are often many other factors, usually well-defined, surgical, medical, and legitimate reasons, that may contributed to the requirement of opioids following index surgical events that are wholly unrelated to the opioid itself.

Optimization of intraoperative opioids may even REDUCE the risk of post-operative pain, new chronic pain diagnoses, and long-term, persistent opioid use!

How ‘bout them apples!!

 

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