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Figure 1.
Proportions of Patients With Ongoing Opioid Use at 180 Days, 270 Days, and 1 Year After Major Elective Surgery
Proportions of Patients With Ongoing Opioid Use at 180 Days, 270 Days, and 1 Year After Major Elective Surgery

The proportion of individuals with ongoing opioid use at 180 days, 270 days, and 1 year after surgery, with error bars denoting exact 95% CIs. Proportions are presented for the entire study cohort as well as specific procedure subgroups, namely thoracic, coronary artery bypass graft, abdominal, urologic, and gynecologic procedures.

Figure 2.
Proportions of Patients With Ongoing Opioid Use at 180 Days, 270 Days, and 1 Year After Major Elective Surgery, Stratified by Type of Surgical Approach
Proportions of Patients With Ongoing Opioid Use at 180 Days, 270 Days, and 1 Year After Major Elective Surgery, Stratified by Type of Surgical Approach

The proportion of individuals with ongoing opioid use at 180 days, 270 days, and 1 year, with error bars denoting exact 95% CIs. Proportions are presented for thoracic, abdominal, and gynecologic procedures, as stratified by open vs minimally invasive (MI) approach.

1.
Chou  R, Turner  JA, Devine  EB,  et al.  The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.  Ann Intern Med. 2015;162(4):276-286.PubMedGoogle ScholarCrossref
2.
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
3.
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
4.
Hetmann  F, Kongsgaard  UE, Sandvik  L, Schou-Bredal  I.  Prevalence and predictors of persistent post-surgical pain 12 months after thoracotomy.  Acta Anaesthesiol Scand. 2015;59(6):740-748.PubMedGoogle ScholarCrossref
5.
Bateman  BT, Franklin  JM, Bykov  K,  et al.  Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women.  Am J Obstet Gynecol. 2016;S0002-9378(16)00478-6.PubMedGoogle Scholar
6.
Katz  J, Weinrib  A, Fashler  SR,  et al.  The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain.  J Pain Res. 2015;8:695-702.PubMedGoogle ScholarCrossref
Research Letter
November 2016

Risks of Developing Persistent Opioid Use After Major Surgery

Author Affiliations
  • 1Department of Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
  • 2Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
  • 3Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  • 4Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
 

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Surg. 2016;151(11):1083-1084. doi:10.1001/jamasurg.2016.1681

Exposure to opioids is largely unavoidable after major surgery because they are routinely used to treat postoperative pain. Nonetheless, continued long-term opioid use has negative health consequences including opioid dependence.1 Patients and health care professionals are therefore concerned about long-term postoperative opioid use.2 There are limited data on the risk of previously opioid-naive individuals developing persistent postoperative opioid use. In a 2014 population-based cohort study, we found that 3% of previously opioid-naive patients continued to use opioids 3 months after major elective surgery in Ontario, Canada.3 Importantly, the risk of persistent opioid use over longer periods after surgery remains unclear. We therefore conducted a follow-up study to measure rates of ongoing opioid use up to 1 year after major surgery.

Methods

We conducted a retrospective cohort study that was approved by the research ethics board at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. The research ethics board waived the need for written informed consent for this retrospective analysis of anonymized administrative population-based health care data. These databases capture information on outpatient prescriptions dispensed to Ontario residents 65 years or older. The cohort included individuals who were 66 years or older, were opioid naive (ie, no prescription in prior year), and underwent specific major elective surgeries (eg, coronary artery bypass graft surgery via sternotomy; open and minimally invasive lung resection surgery; open and minimally invasive colon resection surgery; open and minimally invasive radical prostatectomy; and open and minimally invasive hysterectomy) from 2003 to 2010. Individuals requiring palliative care services within 1 year before or after surgery were excluded. We measured the time to opioid cessation for any individual receiving an opioid prescription within 90 days after surgery, with the date of cessation defined by the absence of any opioid prescription within the preceding 90 days. We measured the proportion of individuals with ongoing opioid therapy at 180, 270, and 365 days after surgery. Because the included surgeries have different postoperative survival rates, only individuals alive 90 days before the relevant periods were considered when calculating these proportions.

Results

The cohort included 39 140 opioid-naive patients, of whom 53% received 1 or more opioid prescriptions within 90 days after discharge. By 1 year after surgery, only 168 of 37 650 surviving patients (0.4%; 95% CI, 0.3%-0.5%) continued to receive ongoing opioid prescriptions (Figure 1). The highest risk of long-term persistent opioid use occurred after open (37 of 2212 patients [1.7%; 95% CI, 1.2%-2.3%]) and minimally invasive (9 of 669 patients [1.3%; 95% CI, 0.6%-2.5%]) lung resection procedures (Figure 2).

Discussion

Approximately 0.4% of older opioid-naive patients continued to receive ongoing opioid therapy at 1 year after major surgery. The highest risk occurred after thoracic surgery, possibly owing to an increased risk of chronic postsurgical pain.4 Study limitations include a restriction to older individuals, lack of data on indications for opioid use, and inability to determine whether any postoperative deaths were related to opioid exposure.

The estimate of 0.4% of patients continuing to receive opioids at 1 year is consistent with some limited available data. In a cohort of older opioid-naive individuals undergoing low-risk noncardiac surgery, 0.7% received opioid prescriptions both shortly after surgery and 1 year after surgery.2 In a cohort of opioid-naive women undergoing cesarean delivery, 0.36% continued to receive ongoing opioid therapy 1 year after surgery.5 Our study thus provides reassurance that the individual risk of long-term opioid use in opioid-naive surgical patients is low. Conversely, the large volume of surgeries performed annually means that the population burden of long-term postoperative opioid use remains significant. Our study further indicates that interventions for preventing long-term opioid use in opioid-naive surgical patients are best targeted to individuals predisposed to this problem. More research is needed to identify characteristics of such individuals, which should include psychological profiles and intensity of acute postoperative pain.6 Our findings also point to the need for similar research in surgical patients potentially more predisposed to prolonged opioid use, including individuals with chronic pain or preoperative opioid exposure.

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Article Information

Corresponding Author: Hance A. Clarke, MD, PhD, FRCPC, Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, Eaton Wing 3-460, 200 Elizabeth St, Toronto, ON M5G 2C4, Canada (hance.clarke@uhn.ca).

Published Online: August 10, 2016. doi:10.1001/jamasurg.2016.1681.

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

Study concept and design: Soneji, Clarke, Wijeysundera.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Soneji.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Soneji, Ko, Wijeysundera.

Administrative, technical, or material support: Wijeysundera.

Study supervision: Clarke, Wijeysundera.

Conflict of Interest Disclosures: Drs Clarke and Wijeysundera are supported by Merit Awards from the Department of Anesthesia at the University of Toronto. Dr Ko is supported by a Clinician-Scientist Award from the Heart and Stroke Foundation. Dr Wijeysundera is supported by a New Investigator Award from the Canadian Institutes of Health Research.

Funding/Support: This 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.

Roler of the Funder/Sponsor: The funding sources 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.

Disclaimer: The opinions, results, and conclusions are those of the authors, and no endorsement by the Ontario Ministry of Health and Long-Term Care or the Institute for Clinical Evaluative Sciences is intended or should be inferred.

References
1.
Chou  R, Turner  JA, Devine  EB,  et al.  The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.  Ann Intern Med. 2015;162(4):276-286.PubMedGoogle ScholarCrossref
2.
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
3.
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
4.
Hetmann  F, Kongsgaard  UE, Sandvik  L, Schou-Bredal  I.  Prevalence and predictors of persistent post-surgical pain 12 months after thoracotomy.  Acta Anaesthesiol Scand. 2015;59(6):740-748.PubMedGoogle ScholarCrossref
5.
Bateman  BT, Franklin  JM, Bykov  K,  et al.  Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women.  Am J Obstet Gynecol. 2016;S0002-9378(16)00478-6.PubMedGoogle Scholar
6.
Katz  J, Weinrib  A, Fashler  SR,  et al.  The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain.  J Pain Res. 2015;8:695-702.PubMedGoogle ScholarCrossref
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