How 30 opioid pills for surgery turn into a habit

A small number of people—about 6 percent—who had not been taking opioids before an operation, but got them to ease post-surgery pain, are still taking painkillers three to six months later. That’s long after what is considered normal for surgical recovery.

Smokers and those who had a history of alcohol or drug issues were about 30 percent more likely to keep filling prescriptions. People with arthritis were more than 50 percent more likely to do so.

A new study suggests that certain factors make these “opioid-naïve” surgery patients more likely than others to end up refilling their opioid prescriptions for months despite a lack of evidence that the drugs help chronic pain or other long-term issues.

There are more than 50 million surgical procedures in the United States each year. If the new findings hold true for all patients, that would mean about 2 to 3 million people end up taking opioids for months after an operation.

“This points to an under-recognized problem among surgical patients,” says Chad Brummett, the director of the Pain Research division in the University of Michigan Medical School anesthesiology department and first author of the study in JAMA Surgery.

“This is not about the surgery itself, but about the individual who is having the procedure, and some predisposition they may have. And we know that continued opioid use is probably not the right answer for them.”

Opioids before surgery may add risks and cost

Brummett and colleagues are working to find better ways for surgical teams to predict and manage the risk of long-term opioid use among their patients.

“These results show the need for education of surgical providers, to understand when it’s time to stop writing prescriptions for opioids, and to refer patients for assistance from a chronic pain physician,” Brummett says. “We need to be asking patients why they think they still need opioids, and what they’re being used for, not just refilling.”

125 pills

The team drew their findings from more than 36,000 non-elderly adults with private insurance who had only one operation in a two-year period from 2013 to 2014. None had had an opioid prescription for the year preceding their operation.

About 80 percent of the patients had minor operations to remove varicose veins, hemorrhoids, appendixes, prostates, thyroids, and gallbladders, or address hand issues—often through minimally invasive techniques. The rest had major operations such as bariatric surgery, hysterectomy, hernia repair, or surgery to address severe reflux or remove part of their colon.

On average, the patients received a prescription for 30 to 45 tablets of opioids in the weeks immediately before or after their operation. Many surgical practices pre-approve such prescriptions for patients during the pre-operative period so they can fill them before they go to the hospital and have them on hand when they get home.

For the 6 percent or so who were still filling opioid prescriptions three to six months after their operation, the average number of total post-surgery prescriptions was 3.3, adding up to about 125 pills. Other research has shown that long-term prescription opioid use raises the risk of becoming dependent on the drugs for non-medical reasons, or moving to illicit opioid drugs like heroin.

Still a new idea

New chronic pain is a known risk of surgery, and some operations do require opioid use for more than a week or so to control acute pain. Surgeons may even worry that if they limit opioid prescriptions, it will lower the patient-satisfaction scores that can affect how much they are paid by insurers, or cause their staff to have difficult interactions with patients.

But Brummett points to Centers for Disease Control and Prevention guidelines that state clearly that opioids are not appropriate first-line medications for long-term pain control.

Hospital patients on opioids need more monitoring

The data came from IHPI’s store of anonymous private-insurance claims data purchased from Optum. The comparison group included a randomly selected 10 percent sample of adults who did not have surgery or an opioid prescription in a one-year period. The researchers assigned them a fictional “surgery date” and looked for any opioid prescriptions they filled in the 180 days after that.

“To truly confront our nation’s opioid issues, we need to move upstream, toward a preventive model that focuses on the 80 percent of our surgical patients who are not taking opioids,” Brummett says.

“From our interactions with surgeons and their teams through Michigan-OPEN, it’s apparent that it’s still a new idea to many that the prescription they write for a surgery patient is a potential source for new chronic use and even diversion of opioids.

“Surgeons and their teams want to do the right thing, so we need to help them shepherd patients through the surgical path and help them come out healthier.”

The Michigan Department of Health and Human Services and the National Institutes of Health and the Agency for Healthcare Research and Quality funded the work.

Source: University of Michigan