Effect of discharge opioid on persistent postoperative opioid use: a retrospective cohort study comparing tapentadol with oxycodone

Abstract

Summary Opioid harm can vary by opioid type. This observational study examined the effect of opioid type (oxycodone vs. tapentadol) on rates of persistent postoperative opioid use (‘persistence’). We linked hospital and community pharmacy data for surgical patients who were dispensed discharge opioids between 1 January 2016 and 30 September 2021. Patients were grouped by opioid experience (‘opioid‐naive’ having received no opioids in the 3 months before discharge) and formulation of discharge opioid (immediate release only or modified release ± immediate release). Mixed‐effects logistic regression models predicted persistence (continued use of any opioid at 90 days after discharge), controlling for key persistence risk factors. Of the 122,836 patients, 2.31% opioid‐naive and 27.24% opioid‐experienced patients met the criteria for persistence. For opioid‐naive patients receiving immediate release opioids, there was no significant effect of opioid type. Tapentadol modified release was associated with significantly lower odds of persistence compared with oxycodone modified release, OR (95%CI) 0.81 (0.69–0.94) for opioid‐naive patients and 0.81 (0.71–0.93) for opioid‐experienced patients. Among patients who underwent orthopaedic surgery (n = 19,832), regardless of opioid experience or opioid formulation, the odds of persistence were significantly lower for those who received tapentadol compared with oxycodone. This was one of the largest and most extensive studies of persistent postoperative opioid use, and the first that specifically examined persistence with tapentadol. There appeared to be lower odds of persistence for tapentadol compared with oxycodone among key subgroups, including patients prescribed modified release opioids and those undergoing orthopaedic surgery.

Routine use of modified‐release opioids on hospital discharge can no longer be justified

“…We read with interest the study by Lam et al. [1]. This was a retrospective cohort study conducted in four large private hospitals in Australia comparing persistent postoperative opioid use (defined as a current prescription at 90 days following hospital discharge) in surgical patients prescribed immediate release, or modified formulations, of either oxycodone or tapentadol on hospital discharge.…”

“…The lower odds of persistence of opioid use only occurred when modified‐release tapentadol was compared with modified‐release oxycodone, and was not statistically significant when comparing immediate‐release formulations. This distinction is important as the use of postoperative modified‐release opioids is no longer recommended by many worldwide societies due to the risk of persistent postoperative opioid use and opioid‐induced ventilatory impairment [1–5]. Indeed, the findings add to the body of evidence that the use of modified‐release opioids is a significant driver for persistent postoperative opioid use, and that surgical patients should only receive immediate‐release formulations of opioids.…”

“…opioid-induced ventilatory impairment[1][2][3][4][5]. Consequentlyseveral regulatory and national bodies, including the US Food and Drug Administration, the US Centers for Disease Control and Prevention, Australia's Faculty of Pain Medicine and Australia's Therapeutic Goods Administration now advise against the use of modified-release opioids, except for long-term treatment of pain [2-5].…”

For complex problems, there are rarely simple solutions, but many pieces of an important puzzle

“…The original study [1] that prompted these letters was funded by an untied educational grant from Seqirus Pty Ltd (a CSL company).…”

“…In our article [1], we presented original research with 120,000 Australian patients that specifically examined how discharge opioid type can influence rates of persistent postoperative opioid use, after considering and controlling for a range of other well established, and important, risk factors. We welcome the editorial by Bicket et al [2] written to accompany our article.…”