Opioid Use After Open Resection or Video-Assisted Thoracoscopic Surgery for Early-Stage Lung Cancer | Cardiothoracic Surgery | JAMA Oncology | JAMA Network
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Table 1.  Characteristics Associated With Surgery Type in 3900 Patients
Characteristics Associated With Surgery Type in 3900 Patients
Table 2.  Relative Odds of Long-term Opioid Use
Relative Odds of Long-term Opioid Use
1.
Kehlet  H, Jensen  TS, Woolf  CJ.  Persistent postsurgical pain: risk factors and prevention.  Lancet. 2006;367(9522):1618-1625. doi:10.1016/S0140-6736(06)68700-XPubMedGoogle ScholarCrossref
2.
Oh  TK, Jeon  JH, Lee  JM,  et al.  Investigation of opioid use and long-term oncologic outcomes for non–small cell lung cancer patients treated with surgery.  PLoS One. 2017;12(7):e0181672. doi:10.1371/journal.pone.0181672PubMedGoogle ScholarCrossref
3.
Volkow  ND, McLellan  TA, Cotto  JH, Karithanom  M, Weiss  SRB.  Characteristics of opioid prescriptions in 2009.  JAMA. 2011;305(13):1299-1301. doi:10.1001/jama.2011.401PubMedGoogle ScholarCrossref
4.
Wildgaard  K, Ravn  J, Nikolajsen  L, Jakobsen  E, Jensen  TS, Kehlet  H.  Consequences of persistent pain after lung cancer surgery: a nationwide questionnaire study.  Acta Anaesthesiol Scand. 2011;55(1):60-68. doi:10.1111/j.1399-6576.2010.02357.xPubMedGoogle ScholarCrossref
5.
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. doi:10.1136/bmj.g1251PubMedGoogle ScholarCrossref
6.
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
Research Letter
November 2018

Opioid Use After Open Resection or Video-Assisted Thoracoscopic Surgery for Early-Stage Lung Cancer

Author Affiliations
  • 1Institute for Translational Epidemiology and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
  • 2Department of Occupational Medicine, Epidemiology and Prevention, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
  • 3Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
  • 4Department of Medicine, General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
  • 5Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
JAMA Oncol. 2018;4(11):1611-1613. doi:10.1001/jamaoncol.2018.4387

Patients undergoing surgery for early-stage lung cancer often experience persistent postoperative pain; it has been estimated that in 10% of patients the pain can be so intense as to be debilitating.1 While the current standard of care is to prescribe opioids at discharge, this treatment is intended as short-term pain control, not to exceed a few weeks after surgery.2 Medical prescriptions of opioids increase the risk of opioid abuse and overdose.3 Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical technique used in early-stage lung cancer that might reduce the need for opioids compared with traditional open surgery,4 but this has yet to be established.

Methods

The Surveillance, Epidemiology, and End Results linked to the Medicare database was queried to identify patients with stage I primary non–small cell lung cancer who had VATS or open resection between January 1, 2007, to December 31, 2013, the years in which Medicare Part D data are available. Patients were excluded from analysis if they had a record of opioid medication prescribed in the 30 days before surgery; thus, we included only opioid-naive patients. Long-term opioid use was defined as having filled 1 or more prescriptions in the first 90 days after surgery as well another prescription in the 90 and 180 days after surgery.5 Multivariable logistic regression and propensity score matching were used to investigate the associations between surgical type and long-term opioid use. Data analysis was performed between November 3, 2017, to May 15, 2018. The study was approved by Icahn School of Medicine at Mount Sinai Institutional Review Board with waiver of informed consent.

Results

There were 3900 patients with non–small cell lung cancer included in this analysis: 1987 VATS (50.9%) and 1913 open resection (49.1%) patients. A total of 2766 patients (70.9%) were discharged with an opioid prescription, and 603 (15.5%) patients had a record of long-term postoperative use.

Patients who underwent VATS were more likely to be women; older; have a smaller tumor, adenocarcinoma, limited resection, and a lower comorbidity score; belong to a higher income quartile; and live in an urban area. Patients who underwent VATS were significantly less likely to have filled an opioid prescription within 90 days after surgery, had a smaller number of overall opioid prescriptions filled than open resection patients, and were less likely to be long-term opioid users (Table 1).

In the adjusted model, patients were significantly less likely to use opioids long-term if they had VATS (adjusted odds ratio [aOR], 0.69; 95% CI, 0.57-0.84), were older (aOR, 0.96, 95% CI 0.94-0.98), and had higher income (aOR, 0.77, 95% CI 0.60-0.99). Long-term opioid use was significantly more likely in those with a higher comorbidity score (aOR, 1.10; 95% CI, 1.05-1.16), large-cell histology (aOR, 1.88; 95% CI, 1.17-3.00), using sleep medication 30 days before surgery (aOR, 1.72; 95% CI, 1.28-2.32), and with a previous psychiatric condition (aOR, 1.64; 95% CI, 1.28-2.09). After propensity matching, the risk of long-term opioid use was still significantly less in patients who underwent VATS (aOR, 0.52; 95% CI, 0.36-0.75) (Table 2).

Discussion

A total of 15.5% of patients who were not previous opioid users became long-term opioid users after surgery. Our study suggests that surgical invasiveness might play a role in the odds of becoming a long-term opioid user after surgery; patients undergoing VATS were less likely to use opioids both in the immediate postoperative period and long-term, even after adjusting for relevant covariates. A limitation of this claim-based study is the precision of the measurement: we cannot discount, for example, that patients may have been able to acquire opioids from friends or family members. However, this possibility suggests that we are likely underestimating the true proportion of long-term opioid users. The escalating severity of the opioid epidemic in the United States6 highlights the need for additional research into how pain management after surgery might be a contributing factor.

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Article Information

Accepted for Publication: July 25, 2018.

Corresponding Author: Emanuela Taioli, MD, PhD, Institute for Translational Epidemiology and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1133, New York, NY 10029 (emanuela.taioli@mountsinai.org).

Published Online: September 24, 2018. doi:10.1001/jamaoncol.2018.4387

Author Contributions: Dr Taioli had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Tuminello, Schwartz, Flores, Taioli.

Acquisition, analysis, or interpretation of data: Tuminello, Wisnivesky, Schwartz, Liu, Mhango.

Drafting of the manuscript: Tuminello, Schwartz, Mhango, Flores, Taioli.

Critical revision of the manuscript for important intellectual content: Tuminello, Wisnivesky, Schwartz, Liu, Taioli.

Statistical analysis: Tuminello, Liu.

Administrative, technical, or material support: Wisnivesky, Mhango, Flores, Taioli.

Supervision: Schwartz, Taioli.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was partially funded by National Cancer Institute (NCI) grant P30CA196521.

Role of the Funder/Sponsor: The NCI had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This paper was presented at the International Association for the Study of Lung Cancer 19th World Conference on Lung Cancer; September 24, 2018; Toronto, Ontario, Canada.

Additional Contributions: We acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, Centers for Medicaid & Medicare Services; Information Management Service; and the Surveillance, Epidemiology and End-Results (SEER) Program tumor registries in the creation of the SEER Medicare database.

Additional Information: The interpretation and reporting of data from the linked SEER Medicare database were the sole responsibility of the authors.

References
1.
Kehlet  H, Jensen  TS, Woolf  CJ.  Persistent postsurgical pain: risk factors and prevention.  Lancet. 2006;367(9522):1618-1625. doi:10.1016/S0140-6736(06)68700-XPubMedGoogle ScholarCrossref
2.
Oh  TK, Jeon  JH, Lee  JM,  et al.  Investigation of opioid use and long-term oncologic outcomes for non–small cell lung cancer patients treated with surgery.  PLoS One. 2017;12(7):e0181672. doi:10.1371/journal.pone.0181672PubMedGoogle ScholarCrossref
3.
Volkow  ND, McLellan  TA, Cotto  JH, Karithanom  M, Weiss  SRB.  Characteristics of opioid prescriptions in 2009.  JAMA. 2011;305(13):1299-1301. doi:10.1001/jama.2011.401PubMedGoogle ScholarCrossref
4.
Wildgaard  K, Ravn  J, Nikolajsen  L, Jakobsen  E, Jensen  TS, Kehlet  H.  Consequences of persistent pain after lung cancer surgery: a nationwide questionnaire study.  Acta Anaesthesiol Scand. 2011;55(1):60-68. doi:10.1111/j.1399-6576.2010.02357.xPubMedGoogle ScholarCrossref
5.
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. doi:10.1136/bmj.g1251PubMedGoogle ScholarCrossref
6.
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
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