Abstract
Prolonged opioid use after surgery may be associated with opioid dependency and increased health care use. However, published studies have reported varying estimates of the magnitude of prolonged opioid use and risk factors associated with the transition of patients to long-term opioid use. To evaluate the rate and characteristics of patient-level risk factors associated with increased risk of prolonged use of opioids after surgery. For this systematic review and meta-analysis, a search of MEDLINE, Embase, and Google Scholar from inception to August 30, 2017, was performed, with an updated search performed on June 30, 2019. Key words may include opioid analgesics, general surgery, surgical procedures, persistent opioid use, and postoperative pain. Of 7534 articles reviewed, 33 studies were included. Studies were included if they involved participants 18 years or older, evaluated opioid use 3 or more months after surgery, and reported the rate and adjusted risk factors associated with prolonged opioid use after surgery. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed. Two reviewers independently assessed and extracted the relevant data. The weighted pooled rate and odds ratios (ORs) of risk factors were calculated using the random-effects model. The 33 studies included 1 922 743 individuals, with 1 854 006 (96.4%) from the US. In studies with available sex and age information, participants were mostly female (1 031 399; 82.7%) and had a mean (SD) age of 59.3 (12.8) years. The pooled rate of prolonged opioid use after surgery was 6.7% (95% CI, 4.5%-9.8%) but decreased to 1.2% (95% CI, 0.4%-3.9%) in restricted analyses involving only opioid-naive participants at baseline. The risk factors with the strongest associations with prolonged opioid use included preoperative use of opioids (OR, 5.32; 95% CI, 2.94-9.64) or illicit cocaine (OR, 4.34; 95% CI, 1.50-12.58) and a preoperative diagnosis of back pain (OR, 2.05; 95% CI, 1.63-2.58). No significant differences were observed with various study-level factors, including a comparison of major vs minor surgical procedures (pooled rate: 7.0%; 95% CI, 4.9%-9.9% vs 11.1%; 95% CI, 6.0%-19.4%; P = .20). Across all of our analyses, there was substantial variability because of heterogeneity instead of sampling error. The findings suggest that prolonged opioid use after surgery may be a substantial burden to public health. It appears that strategies, such as proactively screening for at-risk individuals, should be prioritized.
Highlights
The misuse, overdose, and abuse of prescription opioids constitute sources of substantial morbidity and mortality in the US and globally.[1,2,3,4,5] Approximately 130 individuals in the US die each day of opioid overdose, with one of the largest proportion of preventable deaths in the US being attributable to opioid-related deaths.[3]
The pooled rate of prolonged opioid use after surgery was 6.7% but decreased to 1.2% in restricted analyses involving only opioid-naive participants at baseline
No significant differences were observed with various study-level factors, including a comparison of major vs minor surgical procedures
Summary
The misuse, overdose, and abuse of prescription opioids constitute sources of substantial morbidity and mortality in the US and globally.[1,2,3,4,5] Approximately 130 individuals in the US die each day of opioid overdose, with one of the largest proportion of preventable deaths in the US being attributable to opioid-related deaths.[3]. Opioids remain the standard of care for treatment of acute and routine postoperative pain,[14,15] and surgical procedures remain the primary reason for exposure to these medications.[12,16] There is substantial variation in opioid prescribing among clinicians, in the quantities and dosages of opioids after common general surgical procedures.[17,18] This variation is further complicated with the potential for misuse and diversion, with 67% to 92% of all opioids prescribed for postoperative pain remaining unused.[19]
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