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Redefining Opioid Use Patterns After Surgical Procedures: Why a New Paradigm Is Critical

Redefining Opioid Use Patterns After Surgical Procedures: Why a New Paradigm Is Critical Invited Commentary | Surgery Redefining Opioid Use Patterns After Surgical Procedures: Why a New Paradigm Is Critical Bhiken I. Naik, MBBCh The risk of developing an opioid use disorder after an elective operation is increasingly recognized. Related article Within the surgical population, patients undergoing major spine operations represent a high-risk Author affiliations and article information are cohort: approximately 20% to 70% of patients use opioids prior to operations, preoperative patient- listed at the end of this article. reported pain scores are high, and 50% to 60% of patients have undergone a previous spine 2 3 procedure. The study by Warner et al addresses an important gap in knowledge regarding patterns of opioid use after major spine operations. The authors undertook a population-based cohort study of 2223 adults who were integrated in the Rochester Epidemiology Project, which links health care records across health care institutions in southeastern Minnesota. This allowed the study team to obtain detailed opioid prescription data, which was critical to define their outcomes of interest. They used the Consortium to Study Opioid Risks and Trends (CONSORT) classification to define longitudinal patterns of prescription opioid availability before and after surgical procedures. (This classification was developed originally to study long-term opioid therapy for noncancer pain in patients who were part of the Group Health Cooperative in Washington State and Kaiser Permanente of Northern California.) The study period was defined as the 180 days before the operation and between 181 and 365 days after the date of hospital discharge. Prescription opioid availability was classified into 4 groups: none (no opioids prescribed), short-term (if the period of prescribed opioids was <90 days), long-term (if the period of prescribed opioids was 90 days and if they either had >10 prescriptions during the period or if they had opioids available for >120 days based on maximal consumption), and episodic (if the prescribing period was >90 days but did not meet the criteria for long-term availability). Successful reduction of opioid use was defined a priori by comparing the preoperative and postoperative study epochs and analyzing transitions between the opioid use groups as follows: short-term to none; episodic to short-term or none; long-term to episodic, short-term, or none; and continued absence of opioid use for those with no preoperative opioid availability. On the basis of the aforementioned classification, the authors demonstrated that successful reduction of postoperative opioid use occurred in 83%, 75%, 80%, and 64% of the patients classified as having none, short-term, episodic, and long-term preoperative opioid availability, respectively. The data in this study are further enriched by the use of an alluvial and heat plot for the subgroups, which provides a clear visualization of postoperative opioid trajectories. Using the CONSORT classification is advantageous because opioid use after surgery becomes nonbinary (glass half empty vs half full) and more descriptive of how the glass is filling or emptying. Using this definition can provide clinicians with a standardized and reproducible framework to help identify patients who are falling outside the bounds of their recovery trajectory. This, in turn, can facilitate early intervention and management to mitigate the risk of developing an opioid use disorder after an operation. A multivariable analysis was also performed to determine associations between preoperative opioid availability and successful reduction in opioid requirements 1 year after the operation. Not surprisingly, the analysis showed that taking opioids prior to an operation, a higher burden of comorbidity, the presence of anxiety, and not being discharged to home after the operation were associated with persistent opioid use. These variables have been previously identified as high risk 1,5 factors for the aforementioned complication. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(6):e209457. doi:10.1001/jamanetworkopen.2020.9457 (Reprinted) June 25, 2020 1/2 JAMA Network Open | Surgery Redefining Opioid Use Patterns After Surgical Procedures: Why a New Paradigm Is Critical Previous studies have described long-term prevalence of opioid use after spine operations. Dunn et al reported that, among patients using opioids prior to surgical procedures, 52% continued to be prescribed opioids 12 months after the procedure, whereas in the preoperative opioid-naive subgroup, 18.3% had a prescription for opioids 1 year after the index procedure. Although point prevalence rates provide an important overview of the extent of opioid use after surgery, they lack the nuanced, granular detail to evaluate the contextual and temporal patterns of opioid use patterns described earlier. One key question that needs to be addressed is the external validity of the study by Warner et al. The study cohort was nested within the Rochester Epidemiology Project with accurate prescription data available for the study, which may not be available in other hospitals and health systems. However, prescription drug monitoring programs provide promising state-level data that can be used to closely monitor prescription medication use before and after operations. It is important that prescription drug monitoring programs be universally used, provide real-time data to maximize utility, be actively managed by the states, and be easy to access and use for research as well as clinical purposes. By incorporating prescription drug monitoring programs into routine clinical care, CONSORT and similar classification systems can better determine patient-level prescription pathways and can potentially mitigate the risk of developing an opioid use disorder. Finally, it is important that the definition of success after spine operations should not be a monochromatic outcome that is solely associated with opioid use reduction. Reduced neurological dysfunction, better quality of life, and improved functional activity are important variables that are interlinked with opioid use in patients with spine-related disease. Although the study by Warner et al provides an improved paradigm of delineating patterns of postoperative opioid use, the lack of functional and quality of life measures precludes the reader from contextualizing opioid use within the framework of psychosocial recovery. This is the critical next logical step for future studies investigating persistent opioid use associated with surgical procedures. ARTICLE INFORMATION Published: June 25, 2020. doi:10.1001/jamanetworkopen.2020.9457 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Naik BI. JAMA Network Open. Corresponding Author: Bhiken I. Naik, MBBCh, Department of Anesthesiology and Neurological Surgery, University of Virginia, 1 Hospital Dr, Box 4748, 1215 Lee St, Charlottesville, VA 22903 (bin4n@virginia.edu). Author Affiliation: Department of Anesthesiology and Neurological Surgery, University of Virginia, Charlottesville. Conflict of Interest Disclosures: None reported. REFERENCES 1. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504 2. Dunn LK, Yerra S, Fang S, et al. Incidence and risk factors for chronic postoperative opioid use after major spine surgery: a cross-sectional study with longitudinal outcome. Anesth Analg. 2018;127(1):247-254. doi:10.1213/ANE. 3. Warner NS, Habermann EB, Hooten WM, et al. Association between spine surgery and availability of opioid medication. JAMA Netw Open. 2020;3(6):e208974. doi:10.1001/jamanetworkopen.2020.8974 4. Boudreau D, Von Korff M, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009;18(12):1166-1175. doi:10.1002/pds.1833 5. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293. doi:10.1001/jamainternmed. 2016.3298 6. Dunn LK, Durieux ME, Fernández LG, et al. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine. 2018;28(1):119-126. doi:10.3171/2017.5.SPINE1734 JAMA Network Open. 2020;3(6):e209457. doi:10.1001/jamanetworkopen.2020.9457 (Reprinted) June 25, 2020 2/2 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Network Open American Medical Association

Redefining Opioid Use Patterns After Surgical Procedures: Why a New Paradigm Is Critical

JAMA Network Open , Volume 3 (6) – Jun 25, 2020

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American Medical Association
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Copyright 2020 Naik BI. JAMA Network Open.
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2574-3805
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10.1001/jamanetworkopen.2020.9457
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Abstract

Invited Commentary | Surgery Redefining Opioid Use Patterns After Surgical Procedures: Why a New Paradigm Is Critical Bhiken I. Naik, MBBCh The risk of developing an opioid use disorder after an elective operation is increasingly recognized. Related article Within the surgical population, patients undergoing major spine operations represent a high-risk Author affiliations and article information are cohort: approximately 20% to 70% of patients use opioids prior to operations, preoperative patient- listed at the end of this article. reported pain scores are high, and 50% to 60% of patients have undergone a previous spine 2 3 procedure. The study by Warner et al addresses an important gap in knowledge regarding patterns of opioid use after major spine operations. The authors undertook a population-based cohort study of 2223 adults who were integrated in the Rochester Epidemiology Project, which links health care records across health care institutions in southeastern Minnesota. This allowed the study team to obtain detailed opioid prescription data, which was critical to define their outcomes of interest. They used the Consortium to Study Opioid Risks and Trends (CONSORT) classification to define longitudinal patterns of prescription opioid availability before and after surgical procedures. (This classification was developed originally to study long-term opioid therapy for noncancer pain in patients who were part of the Group Health Cooperative in Washington State and Kaiser Permanente of Northern California.) The study period was defined as the 180 days before the operation and between 181 and 365 days after the date of hospital discharge. Prescription opioid availability was classified into 4 groups: none (no opioids prescribed), short-term (if the period of prescribed opioids was <90 days), long-term (if the period of prescribed opioids was 90 days and if they either had >10 prescriptions during the period or if they had opioids available for >120 days based on maximal consumption), and episodic (if the prescribing period was >90 days but did not meet the criteria for long-term availability). Successful reduction of opioid use was defined a priori by comparing the preoperative and postoperative study epochs and analyzing transitions between the opioid use groups as follows: short-term to none; episodic to short-term or none; long-term to episodic, short-term, or none; and continued absence of opioid use for those with no preoperative opioid availability. On the basis of the aforementioned classification, the authors demonstrated that successful reduction of postoperative opioid use occurred in 83%, 75%, 80%, and 64% of the patients classified as having none, short-term, episodic, and long-term preoperative opioid availability, respectively. The data in this study are further enriched by the use of an alluvial and heat plot for the subgroups, which provides a clear visualization of postoperative opioid trajectories. Using the CONSORT classification is advantageous because opioid use after surgery becomes nonbinary (glass half empty vs half full) and more descriptive of how the glass is filling or emptying. Using this definition can provide clinicians with a standardized and reproducible framework to help identify patients who are falling outside the bounds of their recovery trajectory. This, in turn, can facilitate early intervention and management to mitigate the risk of developing an opioid use disorder after an operation. A multivariable analysis was also performed to determine associations between preoperative opioid availability and successful reduction in opioid requirements 1 year after the operation. Not surprisingly, the analysis showed that taking opioids prior to an operation, a higher burden of comorbidity, the presence of anxiety, and not being discharged to home after the operation were associated with persistent opioid use. These variables have been previously identified as high risk 1,5 factors for the aforementioned complication. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(6):e209457. doi:10.1001/jamanetworkopen.2020.9457 (Reprinted) June 25, 2020 1/2 JAMA Network Open | Surgery Redefining Opioid Use Patterns After Surgical Procedures: Why a New Paradigm Is Critical Previous studies have described long-term prevalence of opioid use after spine operations. Dunn et al reported that, among patients using opioids prior to surgical procedures, 52% continued to be prescribed opioids 12 months after the procedure, whereas in the preoperative opioid-naive subgroup, 18.3% had a prescription for opioids 1 year after the index procedure. Although point prevalence rates provide an important overview of the extent of opioid use after surgery, they lack the nuanced, granular detail to evaluate the contextual and temporal patterns of opioid use patterns described earlier. One key question that needs to be addressed is the external validity of the study by Warner et al. The study cohort was nested within the Rochester Epidemiology Project with accurate prescription data available for the study, which may not be available in other hospitals and health systems. However, prescription drug monitoring programs provide promising state-level data that can be used to closely monitor prescription medication use before and after operations. It is important that prescription drug monitoring programs be universally used, provide real-time data to maximize utility, be actively managed by the states, and be easy to access and use for research as well as clinical purposes. By incorporating prescription drug monitoring programs into routine clinical care, CONSORT and similar classification systems can better determine patient-level prescription pathways and can potentially mitigate the risk of developing an opioid use disorder. Finally, it is important that the definition of success after spine operations should not be a monochromatic outcome that is solely associated with opioid use reduction. Reduced neurological dysfunction, better quality of life, and improved functional activity are important variables that are interlinked with opioid use in patients with spine-related disease. Although the study by Warner et al provides an improved paradigm of delineating patterns of postoperative opioid use, the lack of functional and quality of life measures precludes the reader from contextualizing opioid use within the framework of psychosocial recovery. This is the critical next logical step for future studies investigating persistent opioid use associated with surgical procedures. ARTICLE INFORMATION Published: June 25, 2020. doi:10.1001/jamanetworkopen.2020.9457 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Naik BI. JAMA Network Open. Corresponding Author: Bhiken I. Naik, MBBCh, Department of Anesthesiology and Neurological Surgery, University of Virginia, 1 Hospital Dr, Box 4748, 1215 Lee St, Charlottesville, VA 22903 (bin4n@virginia.edu). Author Affiliation: Department of Anesthesiology and Neurological Surgery, University of Virginia, Charlottesville. Conflict of Interest Disclosures: None reported. REFERENCES 1. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504 2. Dunn LK, Yerra S, Fang S, et al. Incidence and risk factors for chronic postoperative opioid use after major spine surgery: a cross-sectional study with longitudinal outcome. Anesth Analg. 2018;127(1):247-254. doi:10.1213/ANE. 3. Warner NS, Habermann EB, Hooten WM, et al. Association between spine surgery and availability of opioid medication. JAMA Netw Open. 2020;3(6):e208974. doi:10.1001/jamanetworkopen.2020.8974 4. Boudreau D, Von Korff M, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009;18(12):1166-1175. doi:10.1002/pds.1833 5. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293. doi:10.1001/jamainternmed. 2016.3298 6. Dunn LK, Durieux ME, Fernández LG, et al. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine. 2018;28(1):119-126. doi:10.3171/2017.5.SPINE1734 JAMA Network Open. 2020;3(6):e209457. doi:10.1001/jamanetworkopen.2020.9457 (Reprinted) June 25, 2020 2/2

Journal

JAMA Network OpenAmerican Medical Association

Published: Jun 25, 2020

References