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Persistent Opioid Use After Cardiac Surgery
Quick Takes
- Persistent opioid use occurs in 10.2% of opioid-naïve patients who undergo CABG and 8.1% who undergo valve surgery.
- Patients prescribed >300 mg of oral morphine equivalents have significantly increased risk of persistent opioid use after CABG or valve surgery.
Study Questions:
What proportion of opioid-naïve patients develop persistent opioid use after coronary artery bypass grafting (CABG) and valve surgery?
Methods:
This is a retrospective cohort study using data from the OptumInsights Informatics Data Mart (Optum), a large, private-payer administrative claims database consisting of a geographically diverse population with 12-15 million covered patients per year. Patients who underwent first-time CABG or valve repair/replacement from January 1, 2004 to December 31, 2016, were examined to determine a cohort that: 1) was opioid-naïve for ≥180 days prior to the operation; 2) filled a prescription for an opioid within 14 days after surgery; and 3) had ≥90 days of postoperative follow-up. Patients who entered palliative care within 1 year after surgery, had preoperative metastatic cancer, or underwent another procedure with general anesthesia within 180 days postoperatively were excluded. Primary outcome was percentage of patients who had opioid dependence at 90-180 days after the index cardiac procedure. Secondary outcomes were percentage of patients who had opioid dependence at 180-270 days after the index cardiac procedure and the association between opioid amount in total oral morphine equivalents (OMEs) prescribed at discharge with likelihood of persistent opioid use within 90-180 days postoperatively. Adjusted logistic regression analysis was performed to determine patient factors associated with persistent opioid use. Cubic splines were used to determine the nonlinear association of OMEs prescribed at discharge with odds of persistent opioid use.
Results:
During the study time period, of 131,620 patients who underwent cardiac surgery, 35,817 were eligible for inclusion in the study. A total of 25,673 patients underwent CABG, while 10,144 patients underwent valve surgery. Overall, 3,430 (9.6%) cardiac surgery patients had new persistent opioid use within 90-180 days postoperatively (after CABG n = 2,609 or 10.2%; after valve surgery n = 821 or 8.1%). Within 180-270 days postoperatively, 2,285 (8.9%) patients after CABG and 730 (7.2%) patients after valve surgery had persistent opioid use. New persistent opioid use within 90-180 days after cardiac surgery was less likely to occur in patients who underwent valve surgery (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.70-0.86; p < 0.001) and men (OR, 0.87; 95% CI, 0.79-0.97; p < 0.01). It was more likely to occur in patients with congestive heart failure (OR, 1.17; 95% CI, 1.06-1.30; p = 0.002), chronic lung disease (OR, 1.31; 95% CI, 1.19-1.45; p < 0.001), diabetes (OR, 1.27; 95% CI, 1.15-1.40; p < 0.001), renal failure (OR, 1.17; 95% CI, 1.00-1.37; p = 0.048), and liver disease (OR, 1.29; 95% CI, 1.02-1.64; p = 0.03). Additionally, patients with chronic pain (OR, 2.73; 95% CI, 2.10-3.56; p < 0.001), alcoholism (OR, 1.56; 95% CI, 1.23-2.00; p < 0.001), and use of preoperative muscle relaxants (OR, 1.71; 95% CI, 1.52-1.91; p < 0.001) or benzodiazepines (OR, 1.71; 95% CI, 1.52-1.91; p < 0.001) were at increased risk for persistent opioid use. Patients who were prescribed >300 mg OME at discharge (which was the median value for the cohort) had significantly increased risk for developing persistent opioid use.
Conclusions:
New persistent opioid use within 90-180 days occurs in 9.6% of patients after first-time CABG or valve surgery. Women, patients with more comorbidities, and those prescribed >300 mg OME at discharge are at increased risk for developing persistent opioid use postoperatively.
Perspective:
Opioids have been used extensively after cardiac procedures to treat postoperative pain from significant incisions (sternotomy, thoracotomy). However, with the public health crisis of the opioid epidemic in the United States, there has been heightened awareness of the contribution of opioid prescribing after surgical procedures to persistent opioid use and addiction. This study shows that, worrisomely, about 10% of opioid-naïve patients develop new persistent opioid use after cardiac surgery. Preoperative patient factors identified in this study can be used to tailor postoperative opioid prescription for patients at increased risk of developing persistent opioid use. In addition, the study suggests that prescribing <300 mg OME at discharge would decrease risk of new persistent opioid use. Many centers are emphasizing adjunctive nonopioid medications to treat postoperative pain. Additionally, information gleaned from partnerships of statewide quality collaboratives, such as the Michigan Opioid Prescribing Engagement Network (M-OPEN), can further guide surgeons and physicians with evidence-based recommendations and patient education to prevent persistent opioid use and decrease the number of surplus opioid pills in the community.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Novel Agents, Acute Heart Failure, Interventions and Structural Heart Disease
Keywords: Alcoholism, Analgesics, Opioid, Benzodiazepines, Cardiac Surgical Procedures, Chronic Pain, Coronary Artery Bypass, Diabetes Mellitus, Heart Failure, Heart Valve Diseases, Lung Diseases, Public Health, Renal Insufficiency, Secondary Prevention
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