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Factors IDed Boosting Post-Surgical Opioid Risk

Pills on table

(e-Magine Art/Flickr)

13 April 2017. An analysis of insurance claims identifies risk factors behind a sizeable number of people undergoing surgery becoming persistent users of opioid pain drugs long after their procedures. Results of the analysis by a team from University of Michigan medical school in Ann Arbor appear in the 12 April issue of the journal JAMA Surgery.

Opioids work by reducing the intensity of pain signals to the brain, particularly regions of the brain controlling emotion, which reduces effects of the pain stimulus. Examples of leading opioid prescription pain medications are hydrocodone, oxycodon, morphine, fentanyl, and codeine. The illegal drug heroin is also an opioid derivative.

Abuse of opioid pain killers is described by Centers for Disease Control and Prevention as a growing epidemic, fueled in large part by expanding numbers of prescriptions written for pain killing drugs. CDC reported from 1999 to 2015, the amount of prescription opioids in the U.S. quadrupled, despite no overall change in the amount of pain reported by Americans in that period. In addition, says CDC, deaths from overdoses of prescription opioids more than quadrupled since 1999. Today, an average of 91 people in the U.S. die each day from overdoses of heroin or prescription opioids.

The team led by Michigan’s Chad Brummett, professor of anesthesiology and director of the school’s pain research division, sought to document the role played by pain from surgery as a driver of opioid abuse. He and colleagues reviewed insurance claim databases from the health analytics company Optum in 2013-14 for individuals who underwent surgery and with no record of opioid use in the previous year. The researchers selected anonymous records of adults with private insurance, age 18 to 64. The team also selected for comparison a smaller group, about 10 percent, of comparable individuals in the database who did not have surgery.

The surgeries included minor procedures, such as varicose vein removal and carpal tunnel repair making up about 80 percent of the total, as well as major surgeries such as removal of a part of the colon and hysterectomy. Many patients were routinely given opioid prescriptions while in the hospital for pain relief in the 3o to 45 days after leaving the hospital. The researchers looked particularly for evidence of persistent opioid use, defined as records where opioid prescriptions continued more than 90 days following surgery.

The sample yielded some 36,000 individuals meeting the criteria of surgery and no opioid prescriptions in the prior year. Of that number, about 6 percent filled a prescription for opioids in the 90 or more days after their operations. The results show little difference between major surgeries (6.5%) and minor procedures (5.9%). Among the comparable group of adults without surgery in that period, the incidence of persistent opioid use was only 0.4 percent.

The authors also aimed to identify characteristics of these individuals most likely to use opioids for extended periods of time following surgery. The analysis revealed several factors most associated with this outcome, including tobacco use before surgery, alcohol and other substance abuse, mood disorders, anxiety, and previous pain problems, such as back or neck pain.

The authors point out that the problem requires surgeons to better understand their patients’ needs before prescribing opioids. “This is not about the surgery itself,”notes Brummett in a university statement, “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.”

Brummett is co-director of the Michigan Opioid Prescribing Engagement Network, or Michigan-OPEN, that began in October 2016, to encourage better care for surgical pain in the state without setting up patients for an addiction to pain killers. The initiative aims to cut in half the amount of opioid drugs prescribed as well as the number of individuals using opioids well after their surgeries.

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