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Persistent opioid use common after lung cancer surgery
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One of every seven individuals who had not used opioids prior to lung resection appeared at risk for opioid dependence after surgery, according to study results presented at the Annual Meeting of The Society of Thoracic Surgeons.
The two most significant risk factors were receipt of adjuvant therapy and thoracotomy.
More than 63,000 Americans died of drug overdoses in 2016.
“Opioid dependence, misuse and abuse in the United States has continued to rise, with Americans consuming more opioids than any other country,” Alexander A. Brescia, MD, resident in integrated cardiothoracic surgery at University of Michigan, said during a press conference. “We have the highest rate of drug-related deaths in the world. Overdose deaths specifically from opioids have increased 500% from 1999 to 2016, [and] much of [this] has been driven by prescription opioids.”
Opioid use after surgery is one pathway to dependence. Consequently, increased emphasis has been placed on the potential role surgeons may play in reducing the opioid epidemic.
Brescia and colleagues sought to define the rate of new persistent opioid use among opioid-naive patients who underwent surgery for lung cancer in the United States. They additionally assessed risk factors associated with new persistent opioid use among this patient population.
Researchers used insurance claims pooled from the Truven Health MarketScan database to analyze data from 3,026 opioid-naive patients with cancer (mean age, 64 years; 55.2% women) who underwent lung resection between January 2010 and June 2014. Approximately 30% of these patients had anxiety or depression, or suffered from substance abuse.
Exclusion criteria included a hospital stay longer than 30 days, receipt of a subsequent procedure within 180 days of the initial operation, home hospice care or death during initial hospitalization.
Brescia and colleagues defined opioid-naive as no prescriptions filled between 12 months and 31 days prior to surgery.
New persistent opioid use — defined as continued opioid prescription fills between 90 and 180 days following surgery — served as the study’s primary outcome measure.
Mean postoperative length of hospital stay was 5.2 days; 6.5% of patients received neoadjuvant therapy and 21.7% received adjuvant therapy. Nearly 57% of patients underwent thoracotomy and 41% underwent minimally invasive video-assisted thoracoscopic surgery.
Overall, 14% of patients continued to fill opioid prescriptions 3 months to 6 months after lung resection.
A higher percentage of patients who underwent thoracotomy than minimally invasive video-assisted thoracoscopic surgery persistently used opioids (17.1% vs. 9.4%; P < .001). Also, patients who received adjuvant therapy appeared more likely than those who did not receive adjuvant therapy to persistently use opioids (23.9% vs. 11.4%; P < .001).
Multivariable regression analysis identified five factors independently associated with persistent opioid use: receipt of adjuvant therapy (OR= 2.19; 95% CI, 1.74-2.75), thoracotomy (OR = 1.58; 95% CI, 1.24-2.01), male sex (OR = 1.39; 95% CI, 1.12-1.73), postoperative length of stay longer than 5 days (OR = 1.31 (95% CI, 10.5-1.65) and age 64 years or younger (OR = 1.27; 95% CI, 1.02—1.59).
Brescia acknowledged several study limitations, including the use of an employer-based insurance claims database that may not represent a generalizable population. Also, researchers did not assess chronic opioid usage beyond 6 months.
“Future areas of investigation include incorporating risk factors for persistent opioid usage into the development and implementation of evidence-based prescribing guidelines and improving patient education,” Brescia said. – by Jennifer Southall
Reference:
Brescia AA, et al. Factors associated with new persistent opioid use after lung resection. Presented at: Annual Meeting of The Society of Thoracic Surgeons; Jan. 27-31, 2018; Fort Lauderdale, Fla.
Disclosures: Brescia reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.
Perspective
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David Tom Cooke, MD, FACS
This is an excellent study conducted by researchers at the University of Michigan, leaders in the awareness approach and understanding of the role of opioids in the surgical specialty.
There are more deaths from drug overdose in the United States than peak deaths for HIV and gun violence. When we dive deeper into determining the types of drugs that are responsible for these deaths, narcotics and opioids are leading. Epidemics do not discriminate. The majority of deaths from opioid-related drug overdose are occurring in the white community and Native American community, and we have observed a spike in opioid-related drug overdoses in the black and Hispanic communities. This is an epidemic that is affecting all aspects of our society.
The specialty of thoracic surgery has a challenge when it comes to the optimal management of pain. Just as cardiovascular disease and lung cancer are the leading causes of death in the United States, thoracic surgeons have played a leadership role and turned these patients with these diseases into survivors. Brescia and colleagues are the opening salvo of our thoracic surgical community to take control of this situation and play a leadership role.
A key component of this study is that the researchers analyzed the Truven Health MarketScan database, which includes private insurance claims. This really gives us a good impression of what is going on in the surgical community. It does not take into account Medicare or Medicaid recipients who undergo surgery, but that will be the next step in the analysis.
Of note, about one-third of the overall patient population suffered from anxiety. We know that the psychosocial stressors of a cancer diagnosis can affect a patient’s perception of pain. This identifies an area of improvement for thoracic surgeons. We can help these patients before surgery. A second demographic identified in this study was the high prevalence of substance abuse in this population. [This is] yet another opportunity for thoracic surgeons to identify and help these individuals before surgery.
We are in the midst of an opioid epidemic. However, within crisis, there comes opportunity for change. Thoracic surgeons provide leadership and the ability to restore health for our patients.
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