Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period | Geriatrics | JAMA Internal Medicine | JAMA Network
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Leider  HL, Dhaliwal  J, Davis  EJ, Kulakodlu  M, Buikema  AR.  Healthcare costs and nonadherence among chronic opioid users.  Am J Manag Care. 2011;17(1):32-40.PubMedGoogle Scholar
Centers for Disease Control and Prevention (CDC).  Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008.  MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.PubMedGoogle Scholar
Daubresse  M, Chang  HY, Yu  Y,  et al.  Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010.  Med Care. 2013;51(10):870-878.PubMedGoogle ScholarCrossref
Wright  EA, Katz  JN, Abrams  S, Solomon  DH, Losina  E.  Trends in prescription of opioids from 2003-2009 in persons with knee osteoarthritis.  Arthritis Care Res (Hoboken). 2014;66(10):1489-1495.PubMedGoogle ScholarCrossref
Bohnert  AS, Valenstein  M, Bair  MJ,  et al.  Association between opioid prescribing patterns and opioid overdose-related deaths.  JAMA. 2011;305(13):1315-1321.PubMedGoogle ScholarCrossref
Edlund  MJ, Steffick  D, Hudson  T, Harris  KM, Sullivan  M.  Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain.  Pain. 2007;129(3):355-362.PubMedGoogle ScholarCrossref
Edlund  MJ, Martin  BC, Fan  MY, Devries  A, Braden  JB, Sullivan  MD.  Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study.  Drug Alcohol Depend. 2010;112(1-2):90-98.PubMedGoogle ScholarCrossref
Sehgal  N, Manchikanti  L, Smith  HS.  Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse.  Pain Physician. 2012;15(3)(suppl):ES67-ES92.PubMedGoogle Scholar
Alam  A, Gomes  T, Zheng  H, Mamdani  MM, Juurlink  DN, Bell  CM.  Long-term analgesic use after low-risk surgery: a retrospective cohort study.  Arch Intern Med. 2012;172(5):425-430.PubMedGoogle ScholarCrossref
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;348:g1251.PubMedGoogle ScholarCrossref
Raebel  MA, Newcomer  SR, Reifler  LM,  et al.  Chronic use of opioid medications before and after bariatric surgery.  JAMA. 2013;310(13):1369-1376.PubMedGoogle ScholarCrossref
Harden  RN, Bruehl  S, Stanos  S,  et al.  Prospective examination of pain-related and psychological predictors of CRPS-like phenomena following total knee arthroplasty: a preliminary study.  Pain. 2003;106(3):393-400.PubMedGoogle ScholarCrossref
Baker  L, Bundorf  MK, Royalty  A.  Private insurers’ payments for routine physician office visits vary substantially across the United States.  Health Aff (Millwood). 2013;32(9):1583-1590.PubMedGoogle ScholarCrossref
Chernew  ME, Sabik  LM, Chandra  A, Gibson  TB, Newhouse  JP.  Geographic correlation between large-firm commercial spending and Medicare spending.  Am J Manag Care. 2010;16(2):131-138.PubMedGoogle Scholar
Dor  A, Koroukian  S, Xu  F, Stulberg  J, Delaney  C, Cooper  G.  Pricing of surgeries for colon cancer: patient severity and market factors.  Cancer. 2012;118(23):5741-5748.PubMedGoogle ScholarCrossref
Dunn  A, Liebman  E, Pack  S, Shapiro  AH.  Medical care price indexes for patients with employer-provided insurance: nationally representative estimates from MarketScan data.  Health Serv Res. 2013;48(3):1173-1190.PubMedGoogle ScholarCrossref
Macrae  WA.  Chronic post-surgical pain: 10 years on.  Br J Anaesth. 2008;101(1):77-86.PubMedGoogle ScholarCrossref
Karaca-Mandic  P, Jena  AB, Joyce  GF, Goldman  DP.  Out-of-pocket medication costs and use of medications and health care services among children with asthma.  JAMA. 2012;307(12):1284-1291.PubMedGoogle ScholarCrossref
Lin  DY, Psaty  BM, Kronmal  RA.  Assessing the sensitivity of regression results to unmeasured confounders in observational studies.  Biometrics. 1998;54(3):948-963.PubMedGoogle ScholarCrossref
Gomes  T, Mamdani  MM, Paterson  JM, Dhalla  IA, Juurlink  DN.  Trends in high-dose opioid prescribing in Canada.  Can Fam Physician. 2014;60(9):826-832.PubMedGoogle Scholar
King  NB, Fraser  V, Boikos  C, Richardson  R, Harper  S.  Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: a systematic review.  Am J Public Health. 2014;104(8):e32-e42.PubMedGoogle ScholarCrossref
Kehlet  H, Jensen  TS, Woolf  CJ.  Persistent postsurgical pain: risk factors and prevention.  Lancet. 2006;367(9522):1618-1625.PubMedGoogle ScholarCrossref
Humble  SR, Dalton  AJ, Li  L.  A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy.  Eur J Pain. 2014. 2015;19(4):451-465PubMedGoogle ScholarCrossref
Macfarlane  AJ, Prasad  GA, Chan  VW, Brull  R.  Does regional anesthesia improve outcome after total knee arthroplasty?  Clin Orthop Relat Res. 2009;467(9):2379-2402.PubMedGoogle ScholarCrossref
Chan  EY, Fransen  M, Parker  DA, Assam  PN, Chua  N.  Femoral nerve blocks for acute postoperative pain after knee replacement surgery.  Cochrane Database Syst Rev. 2014;5(5):CD009941.PubMedGoogle Scholar
Richman  JM, Liu  SS, Courpas  G,  et al.  Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis.  Anesth Analg. 2006;102(1):248-257.PubMedGoogle ScholarCrossref
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    1 Comment for this article
    Does postop pain relief increase or decrease the risk for later opioid use?
    Peter J Liepmann MD FAAFP | none
    This is important information, and I'm glad the authors plan to follow up to determine what medical interventions might prevent chronic opioid use post-surgery. The authors do not say that opiate use late after surgery represents abuse or addiction. More use of opiates a year after surgery might mean people got activated as abusers because of using opiates post-surgery, or that people having total hip and knee replacements are more likely to have significant pain needing opiates a year later than people having other surgeries or no surgery at all.
    We just don't know which it is.
    The nature
    of the study (retrospective review of administrative records) makes it more difficult to know what might have prevented this, but I wonder whether they can extract information from their data about relief from ACUTE pain postoperatively, and the effectiveness of rehabilitation.
    1. Did more opioid use, or better acute pain relief, immediately post-surgery increase or decrease long term use? (The current belief among pain experts is that better relief of acute pain prevents conditional reinforcement of opioid use, and so would be expected to PREVENT long term use.) It would be useful to confirm or deny this. The unintentional result of this study might be to restrict opiate relief of acute pain, and thus paradoxically increase chronic opioid use and abuse.
    2. Recent literature supports use of multimodal pain relief including intra-articular anesthetic, opiates and NSAIDS, peripheral nerve blocks and epidural analgesia after joint replacement. This seems to reduce pain, opiate need, and to accelerate rehabilitation. Can the authors extract information about the effects of such intervention on late opioid use? Did patients with multimodal pain relief need or use fewer opioids in the late postoperative period?
    CONFLICT OF INTEREST: I have a long-term interest in pain management, and have a suboxone waiver.
    Original Investigation
    September 2016

    Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period

    Author Affiliations
    • 1Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
    • 2Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
    • 3National Bureau of Economic Research, Cambridge, Massachusetts
    JAMA Intern Med. 2016;176(9):1286-1293. doi:10.1001/jamainternmed.2016.3298

    Importance  Chronic opioid use imposes a substantial burden in terms of morbidity and economic costs. Whether opioid-naive patients undergoing surgery are at increased risk for chronic opioid use is unknown, as are the potential risk factors for chronic opioid use following surgery.

    Objective  To characterize the risk of chronic opioid use among opioid-naive patients following 1 of 11 surgical procedures compared with nonsurgical patients.

    Design, Setting, and Participants  Retrospective analysis of administrative health claims to determine the association between chronic opioid use and surgery among privately insured patients between January 1, 2001, and December 31, 2013. The data concluded 11 surgical procedures (total knee arthroplasty [TKA], total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery [FESS], cataract surgery, transurethral prostate resection [TURP], and simple mastectomy). Multivariable logistic regression analysis was performed to control for possible confounders, including sex, age, preoperative history of depression, psychosis, drug or alcohol abuse, and preoperatice use of benzodiazepines, antipsychotics, and antidepressants.

    Exposures  One of the 11 study surgical procedures.

    Main Outcomes and Measures  Chronic opioid use, defined 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.”

    Results  The study included 641 941 opioid-naive surgical patients (169 666 men; mean [SD] age, 44.0 [12.8] years), and 18 011 137 opioid-naive nonsurgical patients (8 849 107 men; mean [SD] age, 42.4 [12.6] years). Among the surgical patients, the incidence of chronic opioid in the first preoperative year ranged from 0.119% for Cesarean delivery (95% CI, 0.104%-0.134%) to 1.41% for TKA (95% CI, 1.29%-1.53%) The baseline incidence of chronic opioid use among the nonsurgical patients was 0.136% (95% CI, 0.134%-0.137%). Except for cataract surgery, laparoscopic appendectomy, FESS, and TURP, all of the surgical procedures were associated with an increased risk of chronic opioid use, with odds ratios ranging from 1.28 (95% CI, 1.12-1.46) for cesarean delivery to 5.10 (95% CI, 4.67-5.58) for TKA. Male sex, age older than 50 years, and preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use were associated with chronic opioid use among surgical patients.

    Conclusions and Relevance  In opioid-naive patients, many surgical procedures are associated with an increased risk of chronic opioid use in the postoperative period. A certain subset of patients (eg, men, elderly patients) may be particularly vulnerable.