JAMA Study Links Surgical Procedures to Post-Operative Chronic Opioid Use

The authors report that the baseline incidence of chronic opioid use among the nonsurgical patients was 0.136 percent and, except for cataract surgery, laparoscopic appendectomy, functional endoscopic sinus surgery, and transurethral prostate resection, all of the surgical procedures were associated with an increased risk of chronic opioid use.

A paper published online July 11 by JAMA Internal Medicine found that some surgical procedures are associated with a higher risk of chronic opioid use after the surgery by opioid-naive patients, with some patient groups, such as elderly males, who may be particularly vulnerable.

The study included 641,941 privately insured patients ages 18 to 64 between Jan. 1, 2001, and Dec. 31, 2013, and 11 surgical procedures: total knee replacement, total hip replacement, laparoscopic gall bladder removal, open gallbladder removal, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery, cataract surgery, transurethral prostate resection, and simple mastectomy. The study's authors (Eric C. Sun, MD, Ph.D.; Beth Darnall, Ph.D.; Laurence C. Baker, Ph.D.; and Dr. Sean Mackey, M.D., Ph.D., of the Stanford University School of Medicine and the National Bureau of Economic Research, Cambridge, Mass.), defined chronic opioid use for the purposes of this study as having filled 10 or more prescriptions or more than 120 days' supply of an opioid in the first year after surgery, excluding the first 90 postoperative days. For nonsurgical patients, chronic opioid use was defined as having filled 10 or more prescriptions or more than 120 days' supply following a randomly assigned surgery date.

They report that the baseline incidence of chronic opioid use among the nonsurgical patients was 0.136 percent and, except for cataract surgery, laparoscopic appendectomy, functional endoscopic sinus surgery, and transurethral prostate resection, all of the surgical procedures were associated with an increased risk of chronic opioid use.

The authors tested for several possible risk factors for chronic opioid use among the surgical patients, including age, sex, history of alcohol or drug abuse, history of depression, and preoperative use of benzodiazepines, antipsychotics, and antidepressants.

"Our study should be viewed in the context of its limitations," they noted. "Our nonsurgical population differed in several ways from our surgical population, and while we controlled for many possible confounders, we cannot exclude the possibility that differences in opioid use between the 2 groups may be due to unobserved confounding. In particular, since pain is often the indication for a given surgery (eg, THA or TKA), one might expect a relatively high baseline incidence of chronic pain (postoperatively) among these patients relative to the general population. However, it is important to note that pain is not the primary indication for all of the procedures we considered. Moreover, even in the cases of TKA and THA, our analysis considered patients whose pain was not sufficient to require opioids prior to their procedure. We were also unable to measure 1 possible confounder, socioeconomic status. We did perform a residual confounding analysis, the results of which suggested that the magnitude of confounding (in terms of the prevalence of a hypothetical confounder among the surgical population and its effect on chronic opioid use) would need to be extremely large to explain our results. Nonetheless, on the whole, more work is needed to establish a definitive causal relationship between surgery and opioid use."

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