Background & Aims
The opioid misuse and abuse epidemic is a public safety crisis impacting people in North America. Personal prescriptions for opioids for pain following surgical or dental procedures are reported to account for a third of misuse or non-medicinal drug use.(1) Prescription drug misuse is defined as the use of any prescription opioid in a way that is not directed by the prescriber. It includes use without a prescription (using another person’s opioid); use in greater amounts, more often or longer than instructed to take the opioid.(2) Although these patients are prescribed opioids they are not routinely screened for risk of prescription opioid misuse. The challenge associated with prescription drug abuse is that opioids have a therapeutic effect in the management of pain that needs to be considered.(3) The aim of this scoping review was to examine the risk factors for prolonged opioid prescription following surgery included published studies from 2018-2020.
Methods
This review was conducted following the JBI methodology for scoping reviews (4). The study population included adults who underwent any surgical procedure who were opioid-naïve prior to their surgery. We excluded studies where we could not separate findings for patients with chronic opioid use and those who were opioid naïve. Our review considered research articles exploring the postoperative use of prescription opioids beyond three months. Review articles were not included, but the reference lists were checked for eligible studies. A comprehensive search of published articles was conducted as per the JBI guideline. We performed a search in MEDLINE and EMBASE, using the keywords: “ Risk assessment, Risk factors, Analgesic Opioid, Opioids*, Pain, and “Pain, post-operative”. Identified articles were imported Covidence for data management and screened for duplicates and relevance prior to data extraction. All screening and extraction occurred by two independent researchers (MS and IN).
Results
A total of 979 studies were screened, with 401 studies sought for retrieval and full text review, 323 studies were excluded (not relevant), leaving 78 studies included in this scoping review. The included surgical procedures fell under the following broad surgical categories: orthopaedic (n=35), spine (n=7), gynecological (n=6), cardiovascular (n=4), urological (n=4), general surgical (n=4), thoracic/lung (n=1) and studies that included all available surgical procedures (n=17).(5-83)
1.7% to 10% of patients continued to fill an opioid prescription more than 90 days after their surgery. Common risk factors for prolonged opioid used included being diagnosed with multiple co-morbid medical conditions, having a cancer diagnosis, being diagnosed with a mental health issue such as anxiety, history of a substance use disorder, tobacco use, and lower socio-economic status. (5-83)
Conclusions
Up to 10% of people who undergo surgical procedures continue to fill a prescription for an opioid analgesic more than 90 days after surgery. It is important that prescribers and healthcare professionals be aware of the risk factors for prolonged opioid use. Future steps should identify strategies to minimize the development of new persistent opioid use after the acute pain period is over.
References
1. Katz N, Fernandez K, Chang A, Benoit C, Butler SF. (2008). Internet-based Survey of
Nonmedical Prescription Opioid Use in the United States. The Clinical Journal of Pain, 24(6), 528-35.
2. Centre for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 Natioanl Suvey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from https://www.samhsa.gov/data/
3. National Advisory Committee on Prescription Drug Misuse. (2013). First do no harm: Responding to Canada’s prescribing drug crisis. Ottawa: Canadian Centre on Substance Abuse. Retrieved from: https://www.ccsa.ca/Resource%20Library/Canada-Strategy-Prescription-Drug-Misuse-Report-en.pdf
4. JBI. Scoping reviews. Resources. https://jbi.global/scoping-review-network/resources.
5. Brown, C. R., Chen, Z., Khurshan, F., Groeneveld, P. W., & Desai, N. D. (2020). Development of Persistent Opioid Use After Cardiac Surgery. JAMA cardiology, 5(8), 889–896. https://doi.org/10.1001/jamacardio.2020.1445
6. Clement, K. C., Canner, J. K., Whitman, G. J. R., Lawton, J. S., Grant, M. C., & Sussman, M. S. (2020). New Persistent Opioid Use After Aortic and Mitral Valve Surgery in Commercially Insured Patients. The Annals of thoracic surgery, 110(3), 829–835. https://doi.org/10.1016/j.athoracsur.2019.12.031
7. Clement, K. C., Canner, J. K., Lawton, J. S., Whitman, G. J. R., Grant, M. C., & Sussman, M. S. (2020). Predictors of new persistent opioid use after coronary artery bypass grafting. The Journal of thoracic and cardiovascular surgery, 160(4), 954–963.e4. https://doi.org/10.1016/j.jtcvs.2019.09.137
8. Ingason, A. B., Geirsson, A., Gudbjartsson, T., Muehlschlegel, J. D., & Sigurdsson, M. I. (2022). The Incidence of New Persistent Opioid Use Following Cardiac Surgery via Sternotomy. The Annals of thoracic surgery, 113(1), 33–40. https://doi.org/10.1016/j.athoracsur.2021.04.030
9.Bicket, M. C., Murimi, I. B., Mansour, O., Wu, C. L., & Alexander, G. C. (2019). Association of new opioid continuation with surgical specialty and type in the United States. American journal of surgery, 218(5), 818–827. https://doi.org/10.1016/j.amjsurg.2019.04.010
10. Falcone M, Luo C, Chen Y, Birtwell D, Cheatle M, Duan R, et al. (2020). Risk of Persistent Opioid Use following Major Surgery in Matched Samples of Patients with and without Cancer. Cancer Epidemiol Biomarkers Prev 1; 29 (11): 2126–2133. https://doi.org/10.1158/1055-9965.EPI-20-0628
11. Howard, R., Brown, C. S., Lai, Y. L., Gunaseelan, V., Brummett, C. M., Englesbe, M., Waljee, J., & Bicket, M. C. (2023). Postoperative Opioid Prescribing and New Persistent Opioid Use: The Risk of Excessive Prescribing. Annals of surgery, 277(6), e1225–e1231. https://doi.org/10.1097/SLA.0000000000005392
12. Karhade, A. V., Cha, T. D., Fogel, H. A., Hershman, S. H., Tobert, D. G., Schoenfeld, A. J., Bono, C. M., & Schwab, J. H. (2020). Predicting prolonged opioid prescriptions in opioid-naïve lumbar spine surgery patients. The spine journal : official journal of the North American Spine Society, 20(6), 888–895. https://doi.org/10.1016/j.spinee.2019.12.019
13. Katzman, C., Harker, E. C., Ahmed, R., Keilin, C. A., Vu, J. V., Cron, D. C., Gunaseelan, V., Lai, Y. L., Brummett, C. M., Englesbe, M. J., & Waljee, J. F. (2021). The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use. Annals of surgery, 274(5), e410–e416. https://doi.org/10.1097/SLA.0000000000003723
14. Scow, J. S., Tomhave, N. M., Lovely, J. K., Spears, G. M., Huebner, M., & Larson, D. W. (2019). Post-Discharge Opioid Prescribing Patterns and Risk Factors in Patients Undergoing Elective Colon and Rectal Surgery Without Complications. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 23(5), 1022–1029. https://doi.org/10.1007/s11605-018-3941-4
15. Namiranian, K., Siglin, J., & Sorkin, J. D. (2021). The incidence of persistent postoperative opioid use among U.S. veterans: A national study to identify risk factors. Journal of clinical anesthesia, 68, 110079. https://doi.org/10.1016/j.jclinane.2020.110079
16. Kassem, H., Urits, I., Shipon, S., Hasoon, J., & Viswanath, O. (2020). The Utility of Percutaneous Balloon Kyphoplasty for Treatment of Traumatic Vertebral Compression Fracture to Prevent Opioid Dependence in a Young Opioid-Dependent Patient. Cureus, 12(8), e9733. https://doi.org/10.7759/cureus.9733
17. Olds, C., Spataro, E., Li, K., Kandathil, C., & Most, S. P. (2019). Assessment of Persistent and Prolonged Postoperative Opioid Use Among Patients Undergoing Plastic and Reconstructive Surgery. JAMA facial plastic surgery, 21(4), 286–291. https://doi.org/10.1001/jamafacial.2018.2035
18. Pitter, F. T., Sikora, M., Lindberg-Larsen, M., Pedersen, A. B., Dahl, B., & Gehrchen, M. (2020). Use of Opioids and Other Analgesics Before and After Primary Surgery for Adult Spinal Deformity: A 10-Year Nationwide Study. Neurospine, 17(1), 237–245. https://doi.org/10.14245/ns.1938106.053
19. Roughead, E. E., Lim, R., Ramsay, E., Moffat, A. K., & Pratt, N. L. (2019). Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study. BMJ open, 9(4), e023990. https://doi.org/10.1136/bmjopen-2018-023990
20. Santosa, K. B., Hu, H. M., Brummett, C. M., Olsen, M. A., Englesbe, M. J., Williams, E. A., & Waljee, J. F. (2020). New persistent opioid use among older patients following surgery: A Medicare claims analysis. Surgery, 167(4), 732–742. https://doi.org/10.1016/j.surg.2019.04.016
21. Simoni, A. H., Nikolajsen, L., Olesen, A. E., Christiansen, C. F., Johnsen, S. P., & Pedersen, A. B. (2020). The association between initial opioid type and long-term opioid use after hip fracture surgery in elderly opioid-naïve patients. Scandinavian journal of pain, 20(4), 755–764. https://doi.org/10.1515/sjpain-2019-0170
22. Svensson, C. J., Lundberg, C. E., Sandström, T. Z., Andrell, P., Thörn, S. E., Rosengren, A., & Wolf, A. (2022). Opioid consumption in patients undergoing Rouxen-Y bariatric surgery compared with population controls with and without obesity. Surgery for Obesity and Related Diseases, 18(1), 107-116.
23. Ung, C., Yonekawa, Y., Waljee, J. F., Gunaseelan, V., Lai, Y. L., & Woodward, M. A. (2021). Persistent Opioid Use after Ophthalmic Surgery in Opioid-Naive Patients and Associated Risk Factors. Ophthalmology, 128(9), 1266–1273. https://doi.org/10.1016/j.ophtha.2021.04.021
24.Wunsch, H., Hill, A. D., Bethell, J., Fu, L., Bateman, B. T., Ladha, K. S., Wijeysundera, D. N., & Neuman, M. D. (2023). Surgeon Postoperative Opioid Prescribing Intensity and Risk of Persistent Opioid Use Among Opioid-naive Adult Patients: A Population-based Cohort Study. Annals of surgery, 277(5), 767–774. https://doi.org/10.1097/SLA.0000000000005318
25. Young, J. C., Dasgupta, N., Chidgey, B. A., & Jonsson Funk, M. (2021). Postsurgical Opioid Prescriptions and Risk of Long-term Use: An Observational Cohort Study Across the United States. Annals of surgery, 273(4), 743–750. https://doi.org/10.1097/SLA.0000000000003549
26. Abed, V., Khalily, C. D., Landy, D. C., Lemaster, N. G., & Stone, A. V. (2023). Risk Factors Associated With Prolonged Opioid Use After Revision Total Shoulder Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews, 7(11), e23.00118. https://doi.org/10.5435/JAAOSGlobal-D-23-00118
27. Baron, J. E., Khazi, Z. M., Duchman, K. R., & Westermann, R. W. (2020). Risk Factors for Opioid Use After Patellofemoral Stabilization Surgery: A Population-Based Study of 1,316 Cases. The Iowa orthopaedic journal, 40(2), 37–45.
28. Best MJ, Harris AB, Bansal A, Huish E, Srikumaran U. (2021). Predictors of long-term opioid use after elective primary total shoulder arthroplasty. Orthopedics, 44(1):58-63.
29. Bell, J. E., Sequeira, S. B., Chen, D. Q., Haug, E. C., Werner, B. C., & Browne, J. A. (2020). Preoperative Pain Management: Is Tramadol a Safe Alternative to Traditional Opioids Before Total Hip Arthroplasty?. The Journal of arthroplasty, 35(10), 2886–2891.e1. https://doi.org/10.1016/j.arth.2020.04.093
30. Brock, J. L., Jain, N., Phillips, F. M., Malik, A. T., & Khan, S. N. (2019). Postoperative opioid cessation rates based on preoperative opioid use: analysis of common orthopaedic procedures. The bone & joint journal, 101-B(12), 1570–1577. https://doi.org/10.1302/0301-620X.101B12.BJJ-2019-0080.R2
31. Broggi, M. S., Oladeji, P. O., Spenser, C., Kadakia, R. J., & Bariteau, J. T. (2023). Risk Factors for Prolonged Opioid Use After Ankle Fracture Surgery. Foot & ankle specialist, 16(5), 476–484. https://doi.org/10.1177/19386400211029123
32. Chalmers BP, Lebowitz J, Chiu Y-F, Joseph AD, Padgett DE, Bostrom MPG, et al. 2021. The Effect of Preoperative Tramadol Use on Postoperative Opioid Prescriptions After Primary Total Hip and Knee Arthroplasty: An Institutional Experience of 11,000 Patients. The Journal of Arthroplasty, 37, S465-470.
33. Chen EY, Lasky R, Dotterweich WA, et al. Chronic Prescription Opioid Use Before and After Total Hip and Knee Arthroplasty in Patients Younger Than 65 Years. The Journal of Arthroplasty. 2019 Oct;34(10):2319-2323. DOI: 10.1016/j.arth.2019.05.050. PMID: 31255407.
34. Cook, D. J., Kaskovich, S. W., Pirkle, S. C., Mica, M. A. C., Shi, L. L., & Lee, M. J. (2019). Benchmarks of Duration and Magnitude of Opioid Consumption After Total Hip and Knee Arthroplasty: A Database Analysis of 69,368 Patients. The Journal of arthroplasty, 34(4), 638–644.e1. https://doi.org/10.1016/j.arth.2018.12.023
35. Degen, R. M., McClure, J. A., Le, B., Welk, B., & Marsh, J. (2021). Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 29(8), 2437–2445. https://doi.org/10.1007/s00167-021-06511-0
36. Edwards, N. M., Varnum, C., Overgaard, S., Nikolajsen, L., Christiansen, C. F., & Pedersen, A. B. (2021). Risk factors for new chronic opioid use after hip fracture surgery: a Danish nationwide cohort study from 2005 to 2016 using the Danish multidisciplinary hip fracture registry. BMJ open, 11(3), e039238. https://doi.org/10.1136/bmjopen-2020-039238
37. Finney, F. T., Gossett, T. D., Hu, H. M., Waljee, J. F., Brummett, C. M., Talusan, P. G., & Holmes, J. R. (2019). New Persistent Opioid Use Following Common Forefoot Procedures for the Treatment of Hallux Valgus. The Journal of bone and joint surgery. American volume, 101(8), 722–729. https://doi.org/10.2106/JBJS.18.00793
38. Gil, J. A., Gunaseelan, V., DeFroda, S. F., Brummett, C. M., Bedi, A., & Waljee, J. F. (2019). Risk of Prolonged Opioid Use Among Opioid-Naïve Patients After Common Shoulder Arthroscopy Procedures. The American journal of sports medicine, 47(5), 1043–1050. https://doi.org/10.1177/0363546518819780
40. Gossett, T. D., Finney, F. T., Hu, H. M., Waljee, J. F., Brummett, C. M., Walton, D. M., & Holmes, J. R. (2019). New Persistent Opioid Use and Associated Risk Factors Following Treatment of Ankle Fractures. Foot & ankle international, 40(9), 1043–1051. https://doi.org/10.1177/1071100719851117
41. Jaynstein J, Donnell A, Chambers L, Mauffrey C, Parry JA. (2020). The effect of surgical pain severity, preoperative opioid use and patient characteristics on postoperative opioid prescriptions and refills in orthopedic surgery. European Journal of Orthopaedic Surgery & Traumatology : Orthopedie Traumatologie. 30(5):781-787. DOI: 10.1007/s00590-020-02628-z. PMID: 31975289.
42. Jørgensen, C. C., Petersen, M., Kehlet, H., & Aasvang, E. K. (2018). Analgesic consumption trajectories in 8975 patients 1 year after fast-track total hip or knee arthroplasty. European journal of pain (London, England), 10.1002/ejp.1232. Advance online publication. https://doi.org/10.1002/ejp.1232
43. Khazi ZM, Baron J, Shamrock A, Gulbrandsen T, Bedard N, Wolf B, et al. (2020). Preoperative Opioid Usage, Male Sex, and Preexisting Knee Osteoarthritis Impacts Opioid Refills After Isolated Arthroscopic Meniscectomy: A Population-Based Study. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 36 (9), 2478-2485
44. Khazi, Z. M., Lu, Y., Patel, B. H., Cancienne, J. M., Werner, B., & Forsythe, B. (2020). Risk factors for opioid use after total shoulder arthroplasty. Journal of shoulder and elbow surgery, 29(2), 235–243. https://doi.org/10.1016/j.jse.2019.06.020
45. Khazi, Z. M., Lu, Y., Shamrock, A. G., Duchman, K. R., Westermann, R. W., & Wolf, B. R. (2019). Opioid use following shoulder stabilization surgery: risk factors for prolonged use. Journal of shoulder and elbow surgery, 28(10), 1928–1935. https://doi.org/10.1016/j.jse.2019.05.026
46. Kluger, M. T., Rice, D. A., Borotkanics, R., Lewis, G. N., Somogyi, A. A., Barratt, D. T., Walker, M., & McNair, P. J. (2022). Factors associated with persistent opioid use 6-12?months after primary total knee arthroplasty. Anaesthesia, 77(8), 882–891. https://doi.org/10.1111/anae.15783
47. Kunkel, S. T., Gregory, J. J., Sabatino, M. J., Borsinger, T. M., Fillingham, Y. A., Jevsevar, D. S., & Moschetti, W. E. (2021). Does Preoperative Opioid Consumption Increase the Risk of Chronic Postoperative Opioid Use After Total Joint Arthroplasty?. Arthroplasty today, 10, 46–50. https://doi.org/10.1016/j.artd.2021.05.012
48. Orfield, N. J., Gaddis, A., Russell, K. B., Hartman, D. W., Apel, P. J., & Mierisch, C. (2020). New Long-Term Opioid Prescription-Filling Behavior Arising in the 15 Months After Orthopaedic Surgery. The Journal of bone and joint surgery. American volume, 102(4), 332–339. https://doi.org/10.2106/JBJS.19.00241
49. Okoroha K.R., Patel R.B., Jildeh T.R., Sanchez N., Sweet M.C., Rill B.K., et al. Pain after anatomic total shoulder arthroplasty versus reverse total shoulder arthroplasty. Orthopedics. 2019;42:E247–E252. doi: 10.3928/01477447-20190125-01
50. Qin MM, Qin CD, Shah CM. Risk factors for prolonged opioid use after open treatment of distal radius fractures. Hand (N Y). 2021;17:1194–1200
51. Rao, A. G., Chan, P. H., Prentice, H. A., Paxton, E. W., Funahashi, T. T., & Maletis, G. B. (2019). Risk Factors for Opioid Use After Anterior Cruciate Ligament Reconstruction. The American journal of sports medicine, 47(9), 2130–2137. https://doi.org/10.1177/0363546519854754
52. Ravi, B., Pincus, D., Croxford, R., Leroux, T., Paterson, J., Hawker, G., & Redelmeier, D. A. (2021). Patterns of pre-operative opioid use affect the risk for complications after total joint replacement. Scientific reports, 11(1), 22124. https://doi.org/10.1038/s41598-021-01179-5
53. Rojas, E. O., Khazi, Z. M., Gulbrandsen, T. R., Shamrock, A. G., Anthony, C. A., Duchman, K., Westermann, R. W., & Wolf, B. R. (2020). Preoperative Opioid Prescription Filling Is a Risk Factor for Prolonged Opioid Use After Elbow Arthroscopy. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 36(8), 2106–2113. https://doi.org/10.1016/j.arthro.2020.04.053
54. Ross, B. J., Wu, V. J., Mansour, A. A., 3rd, Lee, O. C., & Sherman, W. F. (2021). Opioid Claims Prior to Elective Total Joint Arthroplasty and Risk of Prolonged Postoperative Opioid Claims. The Journal of the American Academy of Orthopaedic Surgeons, 29(23), e1254–e1263. https://doi.org/10.5435/JAAOS-D-20-01184
55. Soffin EM, Wilson LA, Liu J, Poeran J, Memtsoudis SG. (2021). Association between sex and perioperative opioid prescribing for total joint arthroplasty: a retrospective population-based study. 125(6)
86. Gomes, T., Mamdani, M.M., Dhalla, I.A., Paterson, J.M., Juurlink, D.N. (2011). Opioid dose and drug-related mortality in patients with nonmalignant pain. Achives of Internal Medicine, 171, 686-69