Abstract
The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood. To characterize the association between preoperative benzodiazepine use and postoperative opioid use and health care costs. In this cohort study, retrospective analysis of private health insurance claims data on 946 561 opioid-naive patients (no opioid prescriptions filled in the year before surgery) throughout the US was conducted. Patients underwent 1 of 11 common surgical procedures between January 1, 2004, and December 31, 2016; data analysis was performed January 9, 2020. Benzodiazepine use, defined as long term (≥10 prescriptions filled or ≥120 days supplied in the year before surgery) or intermittent (any use not meeting the criteria for long term). The primary outcome was opioid use 91 to 365 days after surgery. Secondary outcomes included opioid use 0 to 90 days after surgery and health care costs 0 to 30 days after surgery. In this sample of 946 561 patients, the mean age was 59.8 years (range, 18-89 years); 615 065 were women (65.0%). Of these, 23 484 patients (2.5%) met the criteria for long-term preoperative benzodiazepine use and 47 669 patients (5.0%) met the criteria for intermittent use. After adjusting for confounders, long-term (odds ratio [OR], 1.59; 95% CI, 1.54-1.65; P < .001) and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P < .001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365. For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose (additional 0.6 mean daily morphine milligram equivalents [MMEs]; 95% CI, 0.3-0.8 MMEs; P < .001), although intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, -0.2 to 0.2 MMEs; P = .65). Preoperative benzodiazepine use was also associated with increased opioid use in postoperative days 0 to 90 for both long-term (32% increase, additional 1.9 average daily MMEs; 95% CI, 1.6-2.1 MMEs; P < .001) and intermittent (9% increase, additional 0.5 average daily MMEs; 95% CI, 0.4-0.6 MMEs; P < .001) users. Intermittent benzodiazepine use was associated with an increase in 30-day health care costs ($1155; 95% CI, $938-$1372; P < .001), while no significant difference was observed for long-term benzodiazepine use. The findings of this study suggest that, among opioid-naive patients, preoperative benzodiazepine use may be associated with an increased risk of developing long-term opioid use and increased opioid dosages postoperatively, and also may be associated with increased health care costs.
Highlights
Opioid use remains a public health issue in the US
After adjusting for confounders, long-term and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P < .001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365
For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose, intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, −0.2 to 0.2 MMEs; P = .65)
Summary
Between 1999 and 2017, over 399 000 people died of opioid-related drug overdoses in the US.[1,2] Since 1999, the annual rate of overdose death involving prescription opioids has increased by a factor of 5.1 Numerous opioid-related studies have focused on the perioperative period, which is a time with inherent risk to develop long-term opioid use postoperatively.[3] Opioids are frequently used to treat acute postoperative surgical pain, with more than 80% of patients being prescribed opioids after low-risk surgery.[4] long-term preoperative opioid use has been associated with worse perioperative outcomes, including increased mortality, costs, longer hospital lengths of stay, higher rates of surgical complications, and more frequent readmissions, as well as increased postoperative opioid use.[5,6,7]. In 2008, it was estimated that 5.2% of adults used benzodiazepines, and that use of the drugs increased with age to as high as 8.7% among adults aged 65 to 80 years.[9]
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