Prolonged Postoperative Opioid Use Research Articles

Risk Factors for Prolonged Postoperative Opioid Use After Spine Surgery: A Review of Dispensation Trends From a State-run Prescription Monitoring Program.

Opioid abuse and dependence have a detrimental effect on elective orthopaedic surgeries, yet pain control is an important predictor of postoperative satisfaction. We aimed at better defining risk factors for prolonged postoperative opioid requirements and risk factors for patients requiring higher doses of opioids after spine surgery. The Illinois Prescription Monitoring Program was queried to analyze opioid dispensation patterns at 3 and 6 months postoperatively for adult patients who had spine surgery at a tertiary care hospital by a single surgeon over a 5-year period. Patients were divided into three groups: group 1 patients had opioid dispensed to them 3 and 6 months preoperatively, group 2 patients had opioid dispensed to them only at 3 months preoperatively, and group 3 patients did not have preoperative opioid prescriptions. Demographic characteristics, psychiatric history, smoking status, alcohol use, body mass index, surgical region, and presence of multiple prescribers were abstracted. Statistical analysis included multivariate modified Poisson regression, linear regression, and chi-squared testing when appropriate. Patients in group 1 were at significantly increased risk of continued opioid usage than those in group 2 (relative risk, 3.934; 95% confidence interval, 1.691 to 9.150; P = 0.0015) and those in group 3 (relative risk, 4.004; 95% confidence interval, 1.712 to 9.365; P = 0.0014) at 6 months postoperatively. Group 1 patients also had larger quantities of opioid dispensed to them relative to patients in group 2 or group 3 (P < 0.0001) at 6 months postoperatively. Use of opioid medications at 6 months preoperatively is a risk factor for continued usage and at higher doses 6 months postoperatively. Level III: retrospective cohort study.

Reduction in Narcotic Use After Lumbar Decompression and Fusion in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis.

Study Design:Retrospective cohort study.Objectives:The purpose of this study is to assess change in opioid use before and after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis.Methods:A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Opioid use 6 months preoperatively through 2 years postoperatively was assessed.Results:The study included 13 257 patients that underwent 1-, 2-, or 3-level posterior lumbar instrumented fusion. Overall, 57.8% of patients used opioids preoperatively. Throughout the 6-month preoperative period, 2 368 008 opioid pills were billed for (51.6 opioid pills/opioid user/month). When compared with preoperative opioid use, patients billed fewer opioid medications in the 2-year period postoperatively: 33.6 pills/patient/month (8 851 616 total pills). In a multivariate logistic regression analysis, obesity (odds ratio [OR] 1.10, 95% CI 1.004-1.212), preoperative narcotic use (OR 3.43, 95% CI 3.179-3.708), length of hospital stay (OR 1.02, 95% CI 1.010-1.021), and receiving treatment in the South (OR 1.18, 95% CI 1.074-1.287) or West (OR 1.26, 95% CI 1.095-1.452) were independently associated with prolonged postoperative (>1 year) opioid use. Additionally, males (OR 0.87, 95% CI 0.808-0.945) were less likely to use long-term opioid therapy.Conclusions:This study demonstrates that reduction in opioid use was observed postoperatively in comparison with preoperative values in patients with symptomatic lumbar stenosis or spondylolisthesis that underwent lumbar decompression with fusion. Further prospective studies that are more methodologically stringent are needed to corroborate our findings.

Effect of narcotic prescription limiting legislation on opioid utilization following lumbar spine surgery

Prescription opioid abuse is a public health emergency. Opioid prescriptions for spine patients account for a large proportion of use. Some states have implemented statutory limits on prescribers, however it remains unclear whether such laws are effective. This investigation compares opioid prescription patterns for patients undergoing lumbar spine surgery before and after the passage of statewide narcotic-limiting legislation in Rhode Island. Retrospective review of prospectively-collected medical and pharmacologic data. Two patient cohorts (pre-law January 1, 2016-June 31, 2016 and post-law June 1, 2017-December 31, 2017) that included all patients undergoing selected lumbar spine surgeries (lumbar discectomy, lumbar decompression without fusion, and posterior lumbar fusion). Demographic and surgical variables were collected from the patient's medical charts, and information on controlled substances was collected from the state prescription drug monitoring program database. Variables collected included the number of pills and total morphine milligram equivalents (MMEs) of the first prescription, number of prescriptions filled within 30 days of surgery, total MMEs filled in the 30-day postoperative period, and total MMEs filled from 30 to 90 days after surgery. For comparison of continuous variables, t test or Mann-Whitney U test were used as appropriate. Chi-squared analysis was utilized for comparison of categorical variables. Independent risk factors for prolonged postoperative opioid use were evaluated using logistic regression. There were no significant differences between pre-law (n = 241) and post-law (n = 311) cohorts in terms of age, sex, preoperative opioid use, or preoperative anxiolytic use (p > .05). A greater than 50% decline was observed among all patients from the pre-law to the post-law period in terms of the number of pills (51.61 vs 23.60 pills, p < .001) and MMEs (525.56 vs 218.77 MMEs, p < .001) provided in the first postoperative opioid prescription. The mean total MMEs provided in the first 30 days decreased significantly (891.26 vs 628.63 MMEs, p < .001) despite an increase in the average number of opioid prescriptions filled (1.75 vs 2.04 prescriptions, p = .002) during this time. There was no significant difference in mean MMEs filled from 30 to 90 days. Upon subgroup analysis, there was a statistically significant decline in both the mean first prescription and total 30-day MMEs regardless of preoperative opioid status (all p < .05) or specific procedure performed (all p < .05). Preoperative opioid use was strongly associated with prolonged postoperative opioid requirements throughout the study period (OR 4.71, 95% CI 3.11-7.13, p < .001). There were no significant differences between cohorts in terms of emergency department (ED) visits or unplanned hospital readmissions at 30 and 90 days following surgery (all p > .05). The institution of mandatory statewide opioid prescription limits has resulted in a significant reduction in initial and 30-day opioid prescriptions following lumbar spine surgery. Decreased opioid utilization was observed in all patients, regardless of preoperative opioid tolerance or procedure performed. No significant change in postoperative ED visits or unplanned hospital readmissions was seen following implementation of the legislation. This investigation provides preliminary evidence that narcotic limiting legislation may be effective in decreasing opioid prescriptions after lumbar spine surgery for both opioid-naïve and opioid-tolerant patients.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Surgery and Opioids: 75. Opioid utilization following lumbar arthrodesis: trends and factors associated with long-term use

BACKGROUND CONTEXT Opioid therapy is one of the most effective and commonly practiced methods to control acute postoperative pain. Concerns relating to the overwhelming use of prescription narcotics including an inherent risk of abuse and tolerance has been a contentious issue. In patients undergoing lumbar spine surgery, limited or no data exist on potential risk factors for prolonged postoperative opioid use. In the context of national concern, it is pertinent to define epidemiological trends and risk factors of opioids use in spine patients for practice surveillance, preventive strategies, and patient counseling and welfare. PURPOSE To investigate trends in postoperative narcotic use amongst preoperative opioid users (OU) versus opioid-naive (ON) patients, and identify factors associated with postoperative narcotic use at one year following lumbar arthrodesis. STUDY DESIGN/SETTING Retrospective, observational cohort study. PATIENT SAMPLE A total of 26,553 patients (OU: 58.3%) registered in the Humana Inc. claims dataset (2007 through 2016Q3) that underwent either anterior (ALIF), posterior or transforaminal lumbar interbody fusions (P/TLIFs), postero-lateral fusion (PLF) or a combination of ALIF and PLF. OUTCOME MEASURES Postoperative monthly opioid prescription filling rates up to one year in OUs and ON patients, and risk factors associated with prolonged opioid usage. Prolonged opioid use was defined as narcotic prescription filling at one year following lumbar arthrodesis. METHODS Using the Humana Inc. claims dataset (2007 through 2016Q3), we identified patients undergoing lumbar arthrodesis. Based on preoperative opioid use, patients were identified as an OU (history of the narcotic prescription filled within three months before surgery) or ON (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU and longitudinally tracked up to one year postoperatively for both OU and ON patients. Using log-binomial multivariable regression techniques, factors associated with opioid use at one year following lumbar arthrodesis. In an observational cohort study, we identified patients registered in the Humana Inc. claims dataset (2007 through 2016Q3) who underwent anterior (ALIF) or posterior/transforaminal lumbar interbody fusions (P/TLIFs), or postero-lateral fusion (PLF) or a combination of ALIF and PLF. Based on preoperative opioid use, patients were identified as an OU (history of the narcotic prescription filled within three months before surgery) or an ON (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU and trended for one year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at one year following lumbar surgery. RESULTS Overall, 26,553 patients (OU: 58.3%) underwent lumbar surgery (ALIF:8.5%; P/TLIF:43.8%; PLF:41.5%; ALIF+PLF:6.2%). At one month following surgery, 60.2% NOU and 82.9% OUs had a filled opioid prescription. At three months, rates of prescription opioids declined significantly to 13.9% in NOUs versus 53.8% in OUs, while plateauing at 6-12-month postoperative period (NOU:8.4-9.6%; OU:42.1-45.3%). At one year, significantly higher narcotic prescription filling rates was observed in OUs compared to NOUs (42.4% vs. 8.6%; p CONCLUSIONS Approximately one-third of patients used opioids prior to lumbar spine surgery. Postoperative opioid use fell dramatically during the first three months in ON patients, but nearly half of the preop opioid users will remain on narcotics at one year after primary lumbar arthrodesis. Our findings serve as a baseline in identifying patients at risk for chronic use and encourage discontinuation of opioids prior to lumbar spinal surgery owing to the risks associated with it. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Perioperative Opioid Analgesics and Hip Arthroscopy: Trends, Risk Factors for Prolonged Use, and Complications

The purpose of this article is to (1) examine trends in preoperative and prolonged postoperative opioid analgesic use in patient undergoing hip arthroscopy, (2) characterize risk factors for prolonged opioid analgesic use following hip arthroscopy, and (3) explore preoperative and prolonged postoperative opioid analgesic use as independent risk factors for complications following hip arthroscopy. A private insurance database was queried for patients undergoing hip arthroscopy from 2007 to 2015 with a minimum of 6months of follow-up. Independent risk factors for prolonged opioid analgesic use were determined. Preoperative and prolonged opioid analgesic use as risk factors for complications were examined. There was a significantly decreasing trend in preoperative (P= .002) and prolonged postoperative (P= .009) opioid analgesic use. The most significant risk factor for prolonged postoperative opioid analgesic use was preoperative use (odds ratio [OR], 3.61; P < .0001). Other preoperative prescriptions, including muscle relaxants (OR, 1.5; P < .0001) and anxiolytics (OR, 2.0; P < .0001), were also significant risk factors. Preoperative opioid analgesic use was a significant risk factor for postoperative complications, including emergency room visits (OR, 2.1; P < .0001) and conversion to total hip arthroplasty (THA) (OR, 1.6; P < .0001). Prolonged postoperative opioid analgesic use was associated with a higher risk of revision hip arthroscopy (OR, 1.4; P= .0004) and conversion to THA (OR, 1.8; P < .0001). More than a quarter of patients undergoing hip arthroscopy continue to receive opioid analgesic prescriptions more than 3months postoperatively. The most significant risk factor for prolonged opioid analgesic use is preoperative opioid analgesic use. Additionally, anxiolytics, substance use or abuse, morbid obesity, and back pain were among the more notable risk factors for prolonged postoperative opioid analgesic use. Preoperative and prolonged postoperative opioid analgesic use was associated with a higher likelihood of several adverse effects/complications. Level III, retrospective comparative study.

Risk Factors for Prolonged Postoperative Opioid Use After Spinal Fusion for Adolescent Idiopathic Scoliosis

Risk Factors for Prolonged Postoperative Opioid Use After Spinal Fusion for Adolescent Idiopathic Scoliosis

Risk Factors for Prolonged Postoperative Opioid Use After Spinal Fusion for Adolescent Idiopathic Scoliosis

Risk Factors for Prolonged Postoperative Opioid Use After Spinal Fusion for Adolescent Idiopathic Scoliosis

What factors are associated with increased risk for prolonged postoperative opioid usage after colorectal surgery?

Opioid-related deaths have increased substantially over the last 10years placing clinician's prescription practices under intense scrutiny. Given the substantial risk of opioid dependency after colorectal surgery, we sought to analyze risk of postoperative prolonged opioid use after colorectal resections. Between 2008 and 2014, patients undergoing abdominopelvic procedure with intestinal resection at a tertiary care facility were retrospectively identified. Patient's postoperative narcotic usage including their prescriptions on discharge and their total opioid medication use was recorded. Patient variables such as demographics, surgical characteristics, and prescription use were evaluated. Finally, we developed multivariate models to identify risk factors for prolonged opioid use (> 30 days after incident surgical procedure). We identified 9423 recorded procedures of which 2173 consisted of abdominopelvic procedures with intestinal resection and survived > 1year. Of these, 91% (n = 1981) were discharged on opioids, and 98% (n = 1955) of those patients filled only one prescription. A total of 92 (4%) patients remained on opioids beyond 30days, and from this group, 25% (n = 23 patients) remained at 90days. We found no association between postoperative complications, stoma formation, and patient's sex with risk of prolonged opioid use. However, younger age and history of chronic pain were associated with an increased risk of prolonged opioid use. The use of minimally invasive techniques also attenuated the risk of prolonged opioid use (Table 2). A small but considerable proportion of patients remain on opioids beyond 30 days. Predictors of opioid use for greater than 30 days include a history of chronic pain and younger age. The use of minimally invasive techniques reduced the risk of prolonged opioid use. We identified several immutable risk factors that predicted prolonged postoperative opioid use; however, surgeons may be able to attenuate prolonged opioid use through the use of minimally invasive techniques.

Risk Factors for Prolonged Postoperative Opioid Use After Spinal Fusion for Adolescent Idiopathic Scoliosis.

Opioids are commonly used after posterior spinal instrumented fusion (PSIF) for adolescent idiopathic scoliosis (AIS). Prescription opioids use can potentially lead to misuse, abuse, dependence, and overdose death. Prolonged opioid use has not been extensively studied in the postoperative AIS population. The purpose of this study is to identify risk factors associated with prolonged opioid use after PSIF for AIS. A large insurance database was queried for AIS patients undergoing PSIF. Patients with prolonged postoperative opioid use were defined as those receiving new prescriptions for an opioid medication >6 weeks following the date of surgery, up to 8 months postoperatively. Preoperative and intraoperative risk factors for prolonged opioid use were then examined, including the number of spinal levels fused, preoperative opioid prescriptions, demographic variables, pertinent comorbidities (anxiety, depression, attention deficit hyperactivity disorder, and autism) and other preoperative prescriptions (anxiolytics, antidepressants, nonopioid analgesics, neuropathic medications, and attention deficit hyperactivity disorder medications). Each variable's independent risk for prolonged postoperative opioid use was examined utilizing a multivariable binomial regression analysis. P<0.05 was considered statistically significant. A total of 511 patients were included in the study. Of this 50 patients (9.78%) were found to have prolonged opioid use following scoliosis surgery. Preoperative opioid use (odds ratio, 2.93; P<0.001) was the most significant predictor of prolonged postoperative opioid use. In addition, female sex, obesity, a preoperative diagnosis of anxiety and a preoperative prescription for a muscle relaxer were also significant positive risk factors for prolonged postoperative opioid use. Several factors were found to be protective against prolonged postoperative opioid use. Fewer total fusion levels, compared with ≥13 levels, had a significantly lower risk of prolonged opioid use. Preoperative anxiolytic and antidepressant use were also both negative predictors of prolonged opioid use. Efforts at addressing preoperative opioid use, anxiety, obesity, and providing multimodal pain management strategies should be considered to reduce additional postoperative opioid prescriptions after PSIF for AIS. Level III-retrospective comparative study.

Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures

To evaluate prolonged opioid use in opioid-naïve patients after common hand surgery procedures in the United States. We studied insurance claims from the Truven MarketScan databases to identify opioid-naïve adult patients (no opioid exposure 11 months before the perioperative period) who underwent an elective (carpal tunnel release, carpometacarpal arthroplasty/arthrodesis, cubital tunnel release, or trigger finger release) or trauma-related (closed distal radius fracture fixation, flexor tendon repair, metacarpal fracture fixation, or phalangeal fracture fixation) hand surgery procedure between 2010 and 2012 (N= 77,573 patients). Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. We assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression. In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days compared with trauma patients (13.5% vs 10.5%). Younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use. Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions after hand surgery procedures 90 days after surgery. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States. The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures.

Factors Associated with Opioid Use in a Cohort of Patients Presenting for Surgery.

Objectives. Patients taking opioids prior to surgery experience prolonged postoperative opioid use, worse clinical outcomes, increased pain, and more postoperative complications. We aimed to compare preoperative opioid users to their opioid naïve counterparts to identify differences in baseline characteristics. Methods. 107 patients presenting for thoracotomy, total knee replacement, total hip replacement, radical mastectomy, and lumpectomy were investigated in a cross-sectional study to characterize the associations between measures of pain, substance use, abuse, addiction, sleep, and psychological measures (depressive symptoms, Posttraumatic Stress Disorder symptoms, somatic fear and anxiety, and fear of pain) with opioid use. Results. Every 9-point increase in the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) score was associated with 2.37 (95% CI 1.29–4.32) increased odds of preoperative opioid use (p = 0.0005). The SOAPP-R score was also associated with 3.02 (95% CI 1.36–6.70) increased odds of illicit preoperative opioid use (p = 0.007). Also, every 4-point increase in baseline pain at the future surgical site was associated with 2.85 (95% CI 1.12–7.27) increased odds of legitimate preoperative opioid use (p = 0.03). Discussion. Patients presenting with preoperative opioid use have higher SOAPP-R scores potentially indicating an increased risk for opioid misuse after surgery. In addition, legitimate preoperative opioid use is associated with preexisting pain.

Rates and risk factors for prolonged opioid use after major surgery: population based cohort study

Objective To describe rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery.Design Population based retrospective cohort...