The Correlation between Postoperative Use of Opioids for Acute Pain Management and Long-Term Dependence

In 2015, for the first time in a hundred years, the average life expectancy in the United States entered a period of sustained decline. This has been attributed to a spike in fatal drug overdoses and suicides, both of which are linked to the ongoing opioid epidemic. At the height of the epidemic in 2017, over 47,000 American lives were lost due to opioid-involved drug overdoses, with approximately half of those deaths involving prescription opioids [1]. Prescription opioids, such as oxycodone and hydrocodone, continue to remain a primary component in pain-management, especially among surgical patients in the perioperative and postoperative periods. A recent analysis has found that over 80% of surgical patients receive opioids following a low-risk surgery, thus routinely exposing populations to opioids that have been attributed to drug overdose deaths [2]. Unique risks exist for both opioid-naive and opioid-tolerant patients, with 6% of opioid-naive patients continuing usage after a normal surgical healing period, making it the most common post-surgical complication [3], and opioid-tolerant patients requiring higher doses over extended periods, thus increasing the risks of opioid misuse, dependence, and overdose [4]. As a result, surgeons and anesthesiologists now face a conferred responsibility as significant “gatekeepers” of the ongoing epidemic and must balance perioperative pain management while limiting the risks for postoperative opioid dependence beyond the hospital bed.  

With that being said, there are certain factors the perioperative team can be aware of when prescribing opioids for post-surgical care. A retrospective analysis of 641,941 surgical patients examined correlations between patient characteristics, surgical procedure types, and chronic opioid usage, as defined by 10 or more prescriptions, or more than a 120 days’ supply of an opioid within the first year following surgery excluding the first 90 days. Analysis revealed that the highest incidences of chronic opioid use occurred after total knee arthroplasty, followed by open cholecystectomy, total hip arthroplasty, simple mastectomy, laparoscopic cholecystectomy, open appendectomy, and cesarean delivery, after controlling for age, sex, and preoperative medication usage. Examining patient-level predictors of this cohort revealed that male sex, age greater than 50 years, preoperative use of benzodiazepines or antidepressants, depression history, alcohol abuse history, and drug abuse history increase the risk of chronic opioid usage after the elective procedure [5]. Additional risk factors highlighted in other studies include low socioeconomic status, existing preoperative pain, and the presence of existing medical comorbidities [6].  

In efforts to curb prescription opioid exposure after surgery, professional medical societies and organizations have begun incorporating targeted approaches into operative protocol for subsets of surgical patients who are at increased risk of opioid dependence. For example, patients who have a history of depression are recommended to enroll in cognitive behavioral therapy in an effort to decrease risk of opioid dependence and to improve surgical outcomes. Alternate strategies include expanding the use of regional anesthesia, neuraxial anesthesia, intravenous local anesthesia, and non-opioid medications to decrease opioid consumption following surgery [7].  

Within the next 40 years, the number of Americans age 65 years and older will double. As the American population shifts towards a demographic that is increasingly older, and requires more medical care and procedures, researchers anticipate that the risk of opioid dependence following surgeries will continue to emerge as a rising complication [8].  

References: 

1. Schuchat, Anne et al. “New Data on Opioid Use and Prescribing in the United States.” JAMA vol. 318,5 (2017): 425-426. doi:10.1001/jama.2017.8913 

2. Wunsch H, Wijeysundera DN, Passarella MA, Neuman MD JAMA. 2016 Apr 19; 315(15):1654-7. 

3. 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 

4. Ling W, Mooney L, Hillhouse M. Prescription opioid abuse, pain and addiction: clinical issues and implications. Drug Alcohol Rev. 2011;30(3):300-305. doi:10.1111/j.1465-3362.2010.00271.x 

5. Sun EC, Darnall BD, Baker LC, et al. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA Intern Med. September 1 2016;176(9):1286–1293. 

6. Johnson SP, Chung KC, Zhong L, et al. Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures. J Hand Surg Am. 2016;41(10):947-957.e3. doi:10.1016/j.jhsa.2016.07.113 

7. Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg. 2017;125(5):1733-1740. doi:10.1213/ANE.0000000000002458 

8. Anderson LA, Goodman RA, Holtzman D, Posner SF, Northridge ME. Aging in the United States: opportunities and challenges for public health. Am J Public Health. 2012;102(3):393-395. doi:10.2105/AJPH.2011.300617