Assessment of Persistent and Prolonged Postoperative Opioid Use Among Patients Undergoing Plastic and Reconstructive Surgery

Abstract

IMPORTANCEAlthough the development of persistent opioid use after surgical procedures has garnered much attention in recent years, large-scale studies characterizing patterns of persistent opioid use among patients undergoing plastic and reconstructive surgery procedures are lacking.OBJECTIVE To assess the prevalence of immediate and long-term postoperative opioid use after plastic and reconstructive surgery procedures. DESIGN, SETTING, AND PARTICIPANTSIn this population-based cohort study, patients who underwent 5 classes of plastic and reconstructive procedures (nasal, eye, breast, abdomen, and soft tissue reconstruction) between January 1, 2007, and December 31, 2015, were identified using IBM MarketScan Commercial and Medicare Supplemental research databases. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year preoperatively and postoperatively, had a second anesthesia event within 1 year postoperatively, and filled an opioid prescription within the year prior to surgery. MAIN OUTCOMES AND MEASURESAnalgesic prescription patterns in the immediate postoperative period. The primary outcome was rates of persistent opioid use (opioid prescriptions filled 90-180 days postoperatively). The secondary outcome was rates of prolonged opioid use (opioid prescriptions filled 90-180 days postoperatively and again 181-365 days postoperatively). Explanatory variables included patient demographics, procedure type, and relevant comorbidities. RESULTSOf the 466 677 patients who met inclusion criteria, 96 397 (45.3%) were men, and the mean (SD) age was 46.8 (17.7) years. Furthermore, 212 387 (54.6%) of the patients filled prescriptions for postoperative analgesics, with 212 387 (91.5%) of analgesic prescriptions filled being for opioids. Persistent opioid use occurred in 30 865 (6.6%) patients (5.1%-13.5% across procedure classes), while prolonged opioid use occurred in 10 487 (2.3%) patients (1.7%-5.6% across procedure classes). Patients who filled prescriptions for opioids in the perioperative period were significantly more likely to exhibit persistent (odds ratio [OR], 2.87; 95% CI, 2.80-2.94) and prolonged (OR, 2.90; 95% CI, 2.77-3.02) opioid use than those who did not fill perioperative opioid prescriptions, with the greatest odds for persistent use found in patients who underwent breast (OR, 4.36; 95% CI,) and nasal (OR, 3.51; 95% CI, 3.30-3.73) procedures. On multivariable logistic regression analysis, independent risk factors for persistent and prolonged opioid use included perioperative opioid use, procedure type, and prior-year mental health (depression and anxiety) and substance abuse diagnoses. CONCLUSIONS AND RELEVANCEGiven the significant risk of persistent opioid use after plastic and reconstructive procedures, it is imperative to develop best practices guidelines for postoperative opioid prescription practices in this population.LEVEL OF EVIDENCE NA.

Postoperative opioid‐prescribing practices in otolaryngology: A multiphasic study

“…Otolaryngologic studies report that psychiatric comorbidities, preoperative opioid use, tobacco use, and higher scores on the Charlson Comorbidity Index were associated with longer opioid use. [8][9][10] Prescription size is associated with increased postoperative opioid use: patients consume five additional pills for every 10 pills overprescribed. 11 Another factor influencing opioid use include cultural beliefs.…”

Robot-Assisted Radical Prostatectomy Associated with Decreased Persistent Postoperative Opioid Use

“…3 Prolonged use (>180 days) developed in 2.3% of patients who filled a prescription perioperatively, consistent with rates seen in population studies of major thoracic and abdominal surgeries, 9 as well as plastic and reconstructive surgeries. 8 RARP was associated with a significantly lower overall risk of developing either persistent or prolonged opioid use when compared with ORP despite having the same quantity of opioid prescribed perioperatively (225 mg of OMEs in the period from 30 days preoperatively through 14 days postoperatively). Additional risk factors for persistent or prolonged opioid use included higher CCI scores, tobacco use, alcohol abuse, and living in the south, west, or north central region of the United States.…”

“…This definition of new persistent opioid use is consistent with prior studies and represents a time frame in which routine postoperative recovery would be expected following radical prostatectomy. 3,8 Pharmacy data were collected for 180 days after discharge to determine whether and when opioid prescriptions were filled as well as the duration and types of opioids filled. Dosages for each type of opioid medication were converted into oral morphine equivalents (OMEs).…”

“…We also identified conditions known to increase the risk of opioid overuse based on existing literature, including obesity, current or previous tobacco use, alcohol abuse, drug abuse, and mental health disorders (psychosis or depression), using the ICD-9/ICD-10 diagnosis codes. 3,8,9 Patient comorbidities and the above risk factors were evaluated at the index hospitalization and in the 180-day preoperative period.…”

“…7 In patients undergoing plastic and reconstructive surgery, risks for persistent (between 90 and 180 days after surgery) and prolonged (more than 180 days after surgery) use include being prescribed an opioid in the perioperative setting, procedure type, number of medical comorbidities, and history of mental health disorders or substance abuse. 8 Although work has been done to characterize rates of perioperative opioid use after radical prostatectomy, data on persistent and prolonged opioid use are limited. [9][10][11][12] Robot-assisted radical prostatectomy (RARP) accounts for 85% of radical prostatectomies performed in the United States.…”