Mastectomy, reconstructive surgery for breast cancer may increase chronic opioid use
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Women with breast cancer who underwent mastectomy and reconstructive surgery may be at increased risk for new chronic persistent drug use, according to study results presented at the virtual San Antonio Breast Cancer Symposium.
Age and receipt of chemotherapy also appeared to increase the likelihood that women would become new users of opioids or sedative-hypnotic drugs, as did prior diagnosis of substance abuse or mental health disorders, results of the retrospective cohort study showed.
“What is intended to be a short-term exposure to a controlled substance turns into long-term use of these drugs more often than one would expect,” Jacob Cogan, MD, fellow in hematology/oncology at NewYork-Presbyterian/Columbia University Irving Medical Center, told Healio. “Patients and providers should be aware of this issue, and of the risk factors that place patients at even higher risk.
“Emphasis should be put on only taking these medications when needed, and disposing of them when they are no longer needed,” Cogan added. “This is something providers should follow up about at subsequent clinic visits. In the same way they would ask, ‘How is your pain?’ they should be sure to ask, ‘Are you still taking your opioids? Is the prescription still in your house?’”
Cancer surgery has been associated with postoperative chronic opioid use, with prior studies suggesting up to 10% of patients continue to fill opioid prescriptions more than 3 months after surgery.
However, rates of opioid use after mastectomy and breast reconstruction have not been established. Even less is known about use of sedative-hypnotic medications in this population, according to study background.
“We are concerned that many patients are becoming dependent on controlled substances unnecessarily — ie, using these drugs long-term without a valid medical indication,” Cogan said. “A patient with breast cancer may undergo a mastectomy and reconstruction surgery that cures them of their cancer — or prophylactically prevents them from ever developing cancer — but then become addicted to opioids after the surgery from the prescription they receive for surgical pain. This could be considered a complication of treatment, one that can affect both quality and quantity of life.”
Cogan and colleagues aimed to determine rates of new persistent controlled substance abuse after mastectomy and reconstruction surgery, as well as determine predictors of use in the postoperative period.
They used the MarketScan health care claims database to identify women aged 18 years or older who underwent mastectomy and reconstructive surgery between 2008 and 2017.
They determined which women had received prescriptions for opioids, benzodiazepines, and non-benzodiazepine sedatives or hypnotics during three periods: 365 days to 31 days prior to surgery (preoperative), 31 days prior to 90 days after surgery (perioperative), and 90 days to 365 days after surgery (postoperative).
Researchers excluded women who filled multiple prescriptions for a controlled dangerous substance in the year prior to surgery.
Women who had not used these substances in the preoperative period but filled a minimum of one prescription in the perioperative period and two or more prescriptions in the postoperative period were characterized as new persistent users.
Cogan and colleagues conducted a multivariable logistic regression analysis to identify clinical and demographic factors associated with risk for chronic use for each drug category. These variables included age, insurance status, region, breast cancer diagnosis, chemotherapy receipt, radiation treatment, prior mental health diagnosis and prior substance abuse diagnosis.
Researchers identified 107,725 patients who met inclusion criteria. After excluding patients who did not have continuous insurance coverage and those already characterized as prior persistent users of controlled substances, two groups of eligible patients remained: opioid-naive patients (n = 25,270) and sedative-hypnotic drug-naive patients (n = 27,651).
Among all patients who underwent mastectomy and reconstruction, results showed 13.1% of opioid-naive patients became new persistent opioid users, and 6.6% of sedative-hypnotic drug-naive patients became persistent users of agents in that drug class.
When researchers adjusted the analysis to remove patients who never received or filled prescriptions in the perioperative period, the rates of new persistent use increased for both opioids (17.5%) and sedative-hypnotic drugs (17%).
“It was striking to find that almost one in five patients who receive a prescription for an opioid or sedative-hypnotic medication around the time of their surgery will still be taking that medication up to a year after the surgery,” Cogan said. “We expected that the postsurgical period would be one of high risk for patients, but this was higher than we anticipated.”
Compared with patients aged 70 years or older, younger patients appeared more likely to become new persistent users of opioids (aged 49 years, OR = 1.27; aged 50-64 years, OR = 1.29) and sedative-hypnotic drugs (aged 49 years, OR = 1.79; aged 50-64 years, OR = 1.65).
Other predictors of new persistent use included Medicaid insurance (opioids, OR = 2.31; sedative-hypnotic drugs, OR = 1.85), breast cancer diagnosis vs. prophylactic surgery (opioids, OR = 1.44; sedative-hypnotic drugs, OR = 1.79) and chemotherapy treatment (opioids, OR = 1.33; sedative-hypnotic drugs, OR = 2.24).
As the number of risk factors increased, so did the risk for new persistent use.
Risk for new persistent use was approximately three times as high among patients with five risk factors vs. two risk factors (opioids, OR = 6.34 vs. OR = 2.27; sedative-hypnotic drugs, OR = 7.71 vs. OR = 2.55).
“We don’t mean to suggest that a young patient with Medicaid insurance and a breast cancer diagnosis should not receive opioids for pain after surgery — they absolutely should if necessary,” Cogan said. “However, these are patients that providers should be particularly vigilant about following up with, as they are at high risk [for] becoming dependent on these drugs.”
Additional research is necessary to define the scope of sedative-hypnotic misuse, which Cogan said could be comparable to the opioid epidemic but “hiding in plain sight.”
However, the findings of this study underscore the importance that providers use both pharmacologic and nonpharmacologic strategies to help patients with pain and anxiety around the time of surgery. Providers also must help ensure patients use medications safely and effectively, and help develop interventions that ensure controlled substances are removed from patients’ homes after short-term use, he said.
“I really want to emphasize that we are not suggesting that patients not take these medications,” Cogan told Healio. “In fact, the fear of addiction and side effects may cause patients to avoid these medications when needed, leading them to suffer from untreated pain and anxiety. Additionally, there may be patients captured in our percentages of new persistent users who are using these drugs for reasons that are completely medically appropriate.
“Our concern, however, is the patients who become dependent simply from the exposure to these medications postoperatively” he added. “In other words, once patients’ surgical pain and anxiety/insomnia have resolved, their use of these potentially dangerous medications sometimes persists. This is a problem that deserves attention.”
Perspective
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Sarah P. Cate, MD, FACS
In an era in which opioid overuse is an epidemic, this study brings to light a very important issue.
Current guidelines suggest patients do not need opioid medications for breast conservation surgery or lumpectomy. Rather, we use acetaminophen, NSAIDs such as ketorolac, or other nonnarcotic medications to control pain postoperatively.
Mastectomies with reconstruction are known to cause significantly more pain. Therefore, it is not surprising that these patients took more narcotics. However, from the way the study was conducted, we cannot assume patients took the full prescriptions or exactly how much narcotic medications patients actually took.
Further, there is no long-term follow up for whether patients took more narcotics beyond the preoperative and postoperative period.
Also, the study does not specify the types of reconstruction patients had. Autologous breast reconstruction, or reconstruction using tissue from one’s own body, requires significantly more surgery than implant placement.
This study highlights the need for investigation of nonnarcotic medications and nerve blocks. For example, at my institution, we are using local nerve blocks with long-acting injectable pain medicine. This has greatly decreased hospital stays and narcotic usage.
Blavatnik Family-Chelsea Medical Center at Mount Sinai
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Cogan JC, et al. Abstract GS3-08. Presented at: San Antonio Breast Cancer Symposium (virtual meeting); Dec. 8-11, 2020.
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