Background & Aims
More than 50 million American adults undergo surgery every year and, often, patients are prescribed opioids to treat acute postoperative pain. [1,2] Recent studies have identified risk factors for new persistent opioid use after surgery including prior substance use and psychological conditions such as mood disorders. One specific risk of long-term opioid use after surgery is the initiation of opioid misuse. The incidence of postoperative opioid misuse ranges from 8% [3] to 34% [4] far exceeding the national prevalence of 2% among U.S. adults. As perioperative opioid misuse is specifically associated with increased inpatient mortality, morbidity, and healthcare utilization[5,6], there is an urgent need to identify preoperative risk factors for the development of new onset opioid misuse after surgery.
Methods
Patients undergoing elective surgery at Stanford Hospital from 2019 to 2023 were enrolled in the present study. Patients completed preoperative web-based assessments including the COMM, TAPs tool, BPI, ACE, and PROMIS CAT measures for depression, anxiety, sleep disturbance, and physical function. Patients were asked to complete weekly and monthly post-surgery assessments for up to one year. Patients who did not complete any preoperative surveys or cancelled their surgery were excluded. Patients with a positive preoperative COMM score of greater than or equal to 9 were excluded. SAS Version 9.4 was used for all analyses. Any postoperative opioid misuse (POM) in the first year after surgery was the dependent variable in logistic regression analyses. Multivariable model selection was accomplished by comparing the results of stepwise, backward, and forward variable selection algorithms to determine optimal model fit.
Results
662 (404 (61.6%) Female, 82.8% White/Caucasian, mean age 60.0 (SD 14.6)) patients enrolled, and 79 (12.0%%) reported new-onset POM. Patients who reported POM were younger (55.0 SD 16.0 vs. 60.7 SD 14.2 years) and reported higher pain severity scores before surgery (3.0 SD 2.6 vs. 1.7 SD 2.4). Individuals who developed POM had higher ACE scores, depression, sleep disturbance, and anxiety symptoms; and reduced physical function before surgery. 62.8% of the patients who developed POM reported non-opioid pain medication use before surgery compared to the 48.6% with no POM. In the final model, every 10-point increase in the PROMIS depression score was associated with a 3.35 (95% CI 2.22-5.05) increased odds of POM (p<0.0001), any preoperative opioid use was associated with a 2.97 (95% CI 1.53-5.77) increased odds of POM (p=0.001). Race was a significant predictor of POM (p=0.005) notably compared to White patients, African Americans were at 8.15 (95% CI 2.59-25.63) increased odds of POM.
Conclusions
We identified a number of predictors associated with POM. As preoperative opioid use is a well-established predictor of long-term opioid use after surgery, the incidence of POM among patients taking opioids prior to surgery would likely be elevated. Previous studies have concluded patients experiencing elevated mood with opioids has been reported as a risk factor for opioid misuse post-surgery [6]. Patients with elevated preoperative depressive symptoms may be vulnerable to the mood-elevating effects of opioids placing them at-risk for the development of POM. We identified a significant racial disparity in the development of POM, and future research is needed to identify the underlying causes for this disparity. One possibility may relate to racial disparities in access to high-quality postoperative pain care and downstream disparities in opioid and non-opioid pain medication prescribing. Patients with reduced access to non-opioid pain treatments may be at risk of developing POM.
References
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