Preoperative Opioid Prescription Is Associated With Major Complications in Patients With Crohn’s Disease Undergoing Elective Ileocolic Resection

Abstract

BACKGROUND: Opioid use has grown exponentially over the last decade. The effect of preoperative opioid prescription in patients with Crohn’s disease undergoing surgery is unknown. OBJECTIVE: The purpose of this study was to identify whether preoperative opioid prescription is associated with adverse postoperative outcomes in Crohn’s disease. DESIGN: This is a single-institution retrospective observational study. SETTINGS: This study was performed at an academic tertiary care center. Details of preoperative opioid prescription were collected from the Kentucky All-Schedule Prescription Electronic Reporting database and the electronic databases of bordering states. PATIENTS: Consecutive patients undergoing ileocolic resection for Crohn’s disease from 2014 to 2018 were included. MAIN OUTCOME MEASURES: The outcomes examined were major complications (Clavien–Dindo ≥3a), length of stay, and 30-day hospital readmission. RESULTS: Fifty one of 118 patients were prescribed opioids within 6 months preoperatively (range, 0–33,760 morphine milligram equivalents). Patients with preoperative opioid prescription compared with no preoperative opioid prescription required more daily opioids during hospital admission (p = 0.024). Nineteen patients had a major postoperative complication (preoperative opioid prescription: 26% (13/51) vs no preoperative opioid prescription: 9% (6/67)). On multivariable analysis, preoperative opioid prescription (OR = 2.994 (95% CI, 1.024–8.751); p = 0.045) was a significant risk factor for a major complication. Preoperative opioid prescription was associated with increased length of stay (p < 0.001) and was a risk factor for readmission (OR = 2.978 (95% CI, 1.075–8.246); p = 0.036). Twenty-four patients were readmitted. Using a cutoff for higher opioid prescription of 300 morphine milligram equivalents within 6 months preoperation (eg, 60 tablets of hydrocodone/acetaminophen 5/325), preoperative opioid prescription remained a risk factor for major postoperative complications (OR = 3.148 (95% CI, 1.110–8.928); p = 0.031). LIMITATIONS: This was a retrospective study and could not assess nonprescribed opioid use. CONCLUSIONS: Preoperative opioid prescription was a significant risk factor for adverse outcomes in patients with Crohn’s disease undergoing elective ileocolic resection. See Video Abstract at http://links.lww.com/DCR/B113. LA PRESCRIPCIÓN PREOPERATORIA DE OPIOIDES SE ASOCIA CON COMPLICACIONES MAYORES EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIÓN ILEOCÓLICA ELECTIVA ANTECEDENTES: El uso de opioides ha crecido exponencialmente en la última década. Se desconoce el efecto de la prescripción preoperatoria de opioides en pacientes con enfermedad de Crohn sometidos a cirugía. OBJETIVO: Identificar si la prescripción preoperatoria de opioides está asociada con resultados postoperatorios adversos en la enfermedad de Crohn. DISEÑO. Este es un estudio observacional retrospectivo de una sola institución. AJUSTES: Este estudio se realizó en un centro académico de atención terciaria. Los detalles de la prescripción preoperatoria de opiáceos se recopilaron de la base de datos de “Kentucky All-Schedule Prescription Electronic Reporting” y de las bases de datos electrónicas de los estados fronterizos. PACIENTES: Pacientes consecutivos sometidos a resección ileocólica por enfermedad de Crohn entre 2014-2018. PRINCIPALES MEDIDAS DE RESULTADO: Los resultados examinados fueron complicaciones mayores (Clavien-Dindo ≥3a), duración de la estancia y el reingreso hospitalario de 30 días. RESULTADOS: A cincuenta y uno de 118 pacientes se le recetaron opioides dentro de los 6 meses preoperatorios (rango, 0 a 33,760 equivalentes de miligramos de morfina). Los pacientes con prescripción preoperatoria de opioides en comparación con ninguna prescripción preoperatoria de opioides requirieron más opioides diarios durante el ingreso hospitalario (p = 0,024). Diecinueve pacientes tuvieron una complicación postoperatoria importante (prescripción preoperatoria de opioides: 26% [13/51] frente a ninguna prescripción preoperatoria de opioides: 9% [6/67]). En el análisis multivariable, la prescripción de opioides preoperatorios (OR = 2.994, IC 95%: 1.024-8.751, p = 0.045) fueron factores de riesgo significativos para una complicación mayor. La prescripción preoperatoria de opioides se asoció con un aumento de la duración de la estadía (p <0.001) y fue un factor de riesgo para el reingreso (OR = 2.978, IC 95%: 1.075-8.246, p = 0.036). Veinticuatro pacientes fueron readmitidos. Utilizando un límite para una mayor prescripción de opioides de 300 miligramos equivalentes de morfina dentro de los 6 meses previos a la operación (p. Ej., 60 tabletas de hidrocodona / acetaminofén 5/325), la prescripción preoperatoria de opioides siguió siendo un factor de riesgo para complicaciones postoperatorias mayores (OR = 3.148 IC 95%: 1.110-8.928, p = 0.031). LIMITACIONES: Este fue un estudio retrospectivo y no pudo evaluar el uso de opioides no prescritos. CONCLUSIÓN: La prescripción preoperatoria de opioides fue un factor de riesgo significativo para los resultados adversos en pacientes con enfermedad de Crohn sometidos a resección ileocólica electiva. Consulte Video Resumen en http://links.lww.com/DCR/B113.

Risk Factors for Persistent Postoperative Opioid Use After Surgery for IBD: An Observational Cohort Study

“…6 Chronic opioid use is associated with more frequent hospitalizations and an increased risk of both postoperative complications and long-term mortality for patients having Crohn's disease or ulcerative colitis. [7][8][9] In particular, the duration of postsurgical opioid prescriptions is associated with long-term opioid use. 10,11 Balancing the need for acute pain treatment in the immediate postoperative phase and limiting the use of opioids underlines the importance of considering optimal postoperative pain treatment in this substantial patient group.…”

“…4,5 Chronic opioid use in patients with IBD is a growing problem, [24][25][26] and it is associated with an increased risk of postoperative major complications, a higher rate of hospitalizations and subsequent readmissions for IBD, and increased all-cause mortality. [7][8][9]27 As patients with IBD have a high risk of requiring surgery at least once during their disease course, it is important to consider optimal pain management in this growing patient cohort. A recent study used data from the American College of Surgeons National Surgical Quality Improvement Program to examine risk factors for high inpatient opioid use after surgery.…”

“…Chronic opioid use is associated with more frequent hospitalizations and an increased risk of both postoperative complications and long-term mortality for patients having Crohn’s disease or ulcerative colitis. 7–9 In particular, the duration of postsurgical opioid prescriptions is associated with long-term opioid use. 10,11…”

Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review

“…BMI is a commonly used indicator for body fat and thus a proxy of nutritional status. Preoperative BMI value and the rate of postoperative complications are only moderately correlated, according to abundant reports[ 26 - 30 ]. Nevertheless, clearly underweight patients, defined with varying cut-off values in the literature (from BMI < 16.2 kg/m 2 to BMI < 18.5 kg/m 2 ), are at an increased risk of a dismal postoperative course after intestinal resection, including creation of an ileostomy[ 9 ], readmission[ 31 ], intra-abdominal septic complications (IASCs)[ 32 ], and overall postoperative complications[ 33 , 34 ].…”

“…Elevated levels of the inflammatory markers ( i.e. , leucocyte count) are risk factors for postoperative complications[ 30 , 120 , 121 , 124 ]. Furthermore, a preoperative elevated CRP level has been associated significantly with overall postoperative complications[ 52 , 125 - 127 ], infectious complications[ 33 , 57 , 125 - 127 ], and SSIs[ 57 ].…”