Impact of Prescribing on New Persistent Opioid Use After Cardiothoracic Surgery

Abstract

Background. New persistent opioid use occurs in 3% to 14% of patients after elective surgery, but is poorly described after cardiothoracic surgery. We examined the association of prescription size with new persistent opioid use after cardiothoracic surgery. Methods. Opioid-naive Medicare patients undergoing cardiothoracic surgery between 2009 and 2015 were identified. Patients who filled an opioid prescription between 30 days before surgery and 14 days after discharge and with continuous Medicare enrollment 12 months before and 6 months after surgery were selected (n [ 24,549). New persistent use was defined as continued prescription fills 91 to 180 days after surgery. Prescription size was reported in oral morphine equivalents. Multivariable regression was performed for risk adjustment, and new persistent use rate was estimated. Results. Patient age was 71 ± 8 years, 9222 (38%) were female, and 20,898 (85%) were white. Overall new persistent use was 12.8% (3153 of 24,549), and declined yearly from 17% in 2009 to 7.1% in 2015 (P < .001). Prescription size, preoperative prescription fills, black race, gastrointestinal complications, disability status, open lung resection, dual eligibility (Medicare and Medicaid), drug and substance abuse, female sex, tobacco use, high comorbidity, pain disorders, longer hospital stay, and younger age were associated with new persistent use. Adjusted new persistent use was 19.6% (95% confidence interval, 18.7% to 20.4%) among patients prescribed more than 450 oral morphine equivalents, compared with 10.4% (95% confidence interval, 9.9% to 10.8%) among those prescribed 200 oral morphine equivalents or less (P < .001). Conclusions. Size and timing of perioperative opioid prescriptions were the strongest predictors of new persistent opioid use after cardiothoracic surgery. Modifiable risk factors such as prescription size should be targeted to reduce new persistent use.

Chronic post‐operative opioid use after open cardiac surgery: A Danish population‐based cohort study

“…Pre‐operative naïve patients receiving more than 500 mg OME had a more than threefold risk of becoming chronic post‐operative opioid users compared to patients with no post‐discharge dispensing. These findings are very much aligned with reports from cardiothoracic patients published by Brescia et al describing the adjusted rate of new chronic post‐operative users to be 19.6% among patients with intraoperative prescription size of more than 450 OME with a threshold effect between 300‐450 OME and > 450 OME 28 . Our findings support their conclusion that post‐discharge opioid prescription is a modifiable predictor of new chronic post‐operative opioid use, and clinicians should certainly avoid prescribing more than 60 tablets of 5 mg Oxycodone for full sternotomy.…”

“…Another retrospective study followed opioid naïve Medicare patients undergoing cardiothoracic surgery (coronary artery bypass grafting and/or valve repair/replacement) 6 months after surgery. Chronic post‐operative opioid use was seen in 12.8% of patients 28 . Methodological differences rather than national differences in pain following cardiac surgery may explain this difference.…”

Influence of inpatient opioid consumption on persistent use following total knee arthroplasty

“…Larger amounts of opioid prescribed to patients at the time of hospital discharge have been associated with new, persistent opioid use following many common surgical procedures. [10][11][12][13] These studies suggest that limiting postoperative prescribing can effectively reduce risk among opioid-naïve patients. However, we currently do not know if the amount of opioid consumed by patients recovering in the hospital also plays a role in the development of persistent opioid use.…”

Variability in opioid prescribing practices among cardiac surgeons and trainees

“…Unfortunately, even short postoperative courses can lead to long‐term use and dependency 6 . Following coronary artery bypass grafting (CABG), new persistent use at 3‐months has been identified in up to 12.5% of opioid‐naïve patients 7 . Furthermore, over‐prescription remains a critical issue, as a significant proportion of postsurgical opioids are unused and improperly disposed, contributing to misuse within the community 8 …”

“…6 Following coronary artery bypass grafting (CABG), new persistent use at 3-months has been identified in up to 12.5% of opioid-naïve patients. 7 Furthermore, over-prescription remains a critical issue, as a significant proportion of postsurgical opioids are unused and improperly disposed, contributing to misuse within the community. 8 Standardization in discharge analgesic prescription following cardiac surgery may represent an important target for policy, however, little is known about optimal prescribing regimens and there is potential for wide variation in practice.…”