Elective surgery is a major risk factor for prolonged opioid use; 80% of patients around the world undergoing elective surgeries are given opioids as the primary form of pain control. In fact, a large retrospective analysis found that, of the types of common elective surgery included in the study, only cataract surgery, TURP, laparoscopic appendectomy and FESS were not associated with prolonged opioid use3. Thus, providers frequently must balance adequately controlling real pain after surgery with the risk of dependence on opioid pain medications. Understanding which surgeries carry a higher risk of prolonged opioid use can provide helpful guidance for providers on the type and duration of pain medication to provide postoperatively.
A seven-year-long retrospective cohort study in Canada investigated the major risk factors for prolonged opioid use in patients who underwent elective surgical procedures, including cardiac, thoracic, intra-abdominal and pelvic surgeries2. This study found that prolonged post-discharge opioid use, defined as opioids prescribed for at least 6 months after discharge, was most common in patients who had intrathoracic procedures, both minimally invasive and open lung resections2. The procedures that were least associated with prolonged post-discharge opioids included both minimally invasive and open hysterectomy, and radical prostatectomy2. The increased opioid use associated with thoracic procedures was thought to be due to true postoperative pain; 40-80% of patients report post-thoracotomy pain syndrome six months after having a surgery with thoracotomy incision2. Interestingly, this pain is thought to be neuropathic in nature, and as such does not typically respond well to opioids2. With this knowledge, a more effective pain regimen might include non-opioid medications such as tricyclic antidepressants or gabapentin, with the added bonus of decreasing opiate requirements for these patients2.
While the type of surgery is highly correlated to chronic opioid use, patient and physician factors are also important to consider. Some other factors identified by the study were related more to the likelihood of experiencing prolonged postoperative pain rather than prolonged opioid use2. Younger patients, patients with a chronic history of depression and anxiety, and patients with high levels of acute preoperative fear and anxiety are all more likely to experience increased postoperative pain and therefor utilize opioids for longer periods of time2. Other factors are unrelated to pain; for example, patients on ACE inhibitors were more likely to take opiates for longer than three months postoperatively2. Patients with a history of substance use, especially alcohol or tobacco, were more likely to require opioids for longer than patients without that history1. There was also a dose-dependent indirect association between income level of a patient’s neighborhood and prolonged use of postoperative opioids, which may be due to a complex interaction of social factors2. Ultimately, while the prevalence of postoperative prolonged opioid use is relatively low at 3.1%, it still affects many patients across thousands of surgeries worldwide, and thus care should be taken when prescribing opioids after surgery2.
References
- Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504
- Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population-based cohort study. BMJ. 2014 Feb 11;348:g1251. doi: 10.1136/bmj.g1251.
- Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA Intern Med. 2016;176(9):1286–1293. doi:10.1001/jamainternmed.2016.3298
