RESEARCH
Rates and risk factors for prolonged opioid use after major surgery: population based cohort study Hance Clarke,1 2 3 Neilesh Soneji,2 4 Dennis T Ko,5 6 7 Lingsong Yun,4 Duminda N Wijeysundera1 2 5 7 8 ЖЖEDITORIAL by Dualé 1
Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Eaton North 3 EB 317, Toronto, ON, Canada, M5G 2C4 2 Department of Anesthesia, University of Toronto, Canada 3 Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Canada 4 Department of Anesthesia and Pain Management, Toronto Western Hospital, Canada 5 Institute for Clinical Evaluative Sciences, Toronto, Canada 6 Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada 7 Institute of Health Policy Management and Evaluation, University of Toronto, Canada 8 Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada Correspondence to: H Clarke [email protected] Cite this as: BMJ 2014;348:g1251 doi: 10.1136/bmj.g1251
This is a summary of a paper that was published on bmj.com as BMJ 2014;348:g1251
STUDY QUESTION What are the rates and risk factors for prolonged postoperative opioid use in patients undergoing major elective surgery who have not used opioids previously? SUMMARY ANSWER Approximately 3% of patients who had not used opioids previously continued to use them for more than 90 days after major surgery. Predictors of prolonged use include younger age, lower household income, major thoracic surgery, specific comorbidities (diabetes, heart failure, pulmonary disease), and specific drugs used preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin converting enzyme inhibitors). WHAT IS KNOWN AND WHAT THIS PAPER ADDS The risk of patients who have not previously used opioids developing prolonged opioid use after major surgery is unclear. This study showed the risk to be relatively low at an individual level; none the less, it still represents an important public health concern given the millions of patients who undergo major surgery annually.
Participants and setting This population based study included residents of Ontario, aged 66 years or older, who had not used opioids previously and underwent major elective surgery, including cardiac, intrathoracic, intra-abdominal, and pelvic procedures.
Patient factors significantly predictive of prolonged opioid use Factors
Main results and the role of chance Of the cohort, 49% (n=19 256) were discharged from hospital with an opioid prescription, whereas 3.1% (n=1229) continued to receive opioids for more than 90 days after surgery. Factors associated with significantly higher risks of prolonged opioid use included younger age, lower household income, specific comorbidities, and use of specific drugs preoperatively. Surgical procedure was also highly predictive of prolonged opioid use. Compared with open radical prostatectomies, both open and minimally invasive thoracic procedures were associated with significantly higher risks (odds ratio 2.58, 95% confidence interval 2.03 to 3.28 and 1.95 1.36 to 2.78, respectively). Conversely, open and minimally invasive major gynaecological procedures were associated with significantly lower risks (0.73, 0.55 to 0.98 and 0.45, 0.33 to 0.62, respectively). Bias, confounding, and other reasons for caution Since this study used administrative healthcare data, the indications for opioid prescriptions are unknown and the influence of unmeasured residual confounding cannot be excluded.
Adjusted odds ratio (95% CI)
Age groups (years): 66-75
1.63 (1.08 to 2.46)
76-85
1.47 (0.97 to 2.22)
≥86
Reference
Heart failure
1.32 (1.02 to 1.74)
Diabetes
1.15 (1.00 to 1.31)
Chronic pulmonary disease
1.53 (1.17 to 1.99)
Preoperative treatment: Selective serotonin reuptake inhibitors
1.41 (1.10 to 1.80)
Benzodiazepines
1.26 (1.07 to 1.48)
Angiotensin converting enzyme inhibitors
1.26 (1.09 to 1.44)
BMJ | 1 MARCH 2014 | VOLUME 348
Design, size, and duration This was a retrospective cohort study, performed between 1 April 2003 and 31 March 2010, of 39 140 patients who underwent major elective surgery. We used multivariable logistic regression modelling to determine the adjusted association of patient and surgery characteristics with prolonged postoperative opioid use, which was defined as ongoing outpatient prescriptions for opioids for more than 90 days after surgery.
Generalisability to other populations These results can be reasonably extrapolated to individuals undergoing major elective non-cardiac surgery in healthcare systems that are similar to that in Ontario, Canada. Study funding/potential competing interests The study was supported in part by the Institute for Clinical Evaluative Sciences, which is itself supported in part by the Ontario Ministry of Health and Long-Term Care. HC has externally peer reviewed grant support from Pfizer Canada to evaluate perioperative pregabalin for pain management after hip replacement surgery.
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Copyright of BMJ: British Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Rates and risk factors for prolonged opioid use after major surgery: population based cohort study Hance Clarke,1 2 3 Neilesh Soneji,2 4 Dennis T Ko,5 6 7 Lingsong Yun,4 Duminda N Wijeysundera1 2 5 7 8 ЖЖEDITORIAL by Dualé 1
Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Eaton North 3 EB 317, Toronto, ON, Canada, M5G 2C4 2 Department of Anesthesia, University of Toronto, Canada 3 Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Canada 4 Department of Anesthesia and Pain Management, Toronto Western Hospital, Canada 5 Institute for Clinical Evaluative Sciences, Toronto, Canada 6 Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada 7 Institute of Health Policy Management and Evaluation, University of Toronto, Canada 8 Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada Correspondence to: H Clarke [email protected] Cite this as: BMJ 2014;348:g1251 doi: 10.1136/bmj.g1251
This is a summary of a paper that was published on bmj.com as BMJ 2014;348:g1251
STUDY QUESTION What are the rates and risk factors for prolonged postoperative opioid use in patients undergoing major elective surgery who have not used opioids previously? SUMMARY ANSWER Approximately 3% of patients who had not used opioids previously continued to use them for more than 90 days after major surgery. Predictors of prolonged use include younger age, lower household income, major thoracic surgery, specific comorbidities (diabetes, heart failure, pulmonary disease), and specific drugs used preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin converting enzyme inhibitors). WHAT IS KNOWN AND WHAT THIS PAPER ADDS The risk of patients who have not previously used opioids developing prolonged opioid use after major surgery is unclear. This study showed the risk to be relatively low at an individual level; none the less, it still represents an important public health concern given the millions of patients who undergo major surgery annually.
Participants and setting This population based study included residents of Ontario, aged 66 years or older, who had not used opioids previously and underwent major elective surgery, including cardiac, intrathoracic, intra-abdominal, and pelvic procedures.
Patient factors significantly predictive of prolonged opioid use Factors
Main results and the role of chance Of the cohort, 49% (n=19 256) were discharged from hospital with an opioid prescription, whereas 3.1% (n=1229) continued to receive opioids for more than 90 days after surgery. Factors associated with significantly higher risks of prolonged opioid use included younger age, lower household income, specific comorbidities, and use of specific drugs preoperatively. Surgical procedure was also highly predictive of prolonged opioid use. Compared with open radical prostatectomies, both open and minimally invasive thoracic procedures were associated with significantly higher risks (odds ratio 2.58, 95% confidence interval 2.03 to 3.28 and 1.95 1.36 to 2.78, respectively). Conversely, open and minimally invasive major gynaecological procedures were associated with significantly lower risks (0.73, 0.55 to 0.98 and 0.45, 0.33 to 0.62, respectively). Bias, confounding, and other reasons for caution Since this study used administrative healthcare data, the indications for opioid prescriptions are unknown and the influence of unmeasured residual confounding cannot be excluded.
Adjusted odds ratio (95% CI)
Age groups (years): 66-75
1.63 (1.08 to 2.46)
76-85
1.47 (0.97 to 2.22)
≥86
Reference
Heart failure
1.32 (1.02 to 1.74)
Diabetes
1.15 (1.00 to 1.31)
Chronic pulmonary disease
1.53 (1.17 to 1.99)
Preoperative treatment: Selective serotonin reuptake inhibitors
1.41 (1.10 to 1.80)
Benzodiazepines
1.26 (1.07 to 1.48)
Angiotensin converting enzyme inhibitors
1.26 (1.09 to 1.44)
BMJ | 1 MARCH 2014 | VOLUME 348
Design, size, and duration This was a retrospective cohort study, performed between 1 April 2003 and 31 March 2010, of 39 140 patients who underwent major elective surgery. We used multivariable logistic regression modelling to determine the adjusted association of patient and surgery characteristics with prolonged postoperative opioid use, which was defined as ongoing outpatient prescriptions for opioids for more than 90 days after surgery.
Generalisability to other populations These results can be reasonably extrapolated to individuals undergoing major elective non-cardiac surgery in healthcare systems that are similar to that in Ontario, Canada. Study funding/potential competing interests The study was supported in part by the Institute for Clinical Evaluative Sciences, which is itself supported in part by the Ontario Ministry of Health and Long-Term Care. HC has externally peer reviewed grant support from Pfizer Canada to evaluate perioperative pregabalin for pain management after hip replacement surgery.
11
Copyright of BMJ: British Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
