“[Are] decreasing or increasing opioid prescriptions in the weeks to months before surgery associated with differences in persistent postoperative opioid prescriptions?”

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Aside from the risk of misuse, addiction, overdose, and/or death, chronic preoperative opioid use is associated with numerous facets of postoperative recovery, including rates of surgical complication, length of hospital stay, and hospital readmission.1–3  Increasing recognition of these adverse events has driven efforts to wean opioids in the preoperative setting.4–6  With more than one in four patients who present for surgery reporting preoperative opioid use, such efforts could potentially offer a significant public health impact.7  Results from single-center prospective randomized controlled pilot studies suggest that preoperative opioid weaning interventions (e.g., weekly phone calls guiding and supporting cessation efforts) are feasible and lead to a quicker return-to-baseline and/or cessation of opioids after surgery.5  In a more generalized approach, a single-site retrospective cohort comparison of those patients achieving a 50% reduction in opioids before total joint arthroplasty through self- or physician-guided weaning with unweaned patients suggested that patients who successfully weaned their opioid dose had greater improvements in postoperative outcomes 6 to 12 months after surgery.4  However, it remains unclear whether such weaning practices can translate to larger populations and practice settings. It is also unclear whether such findings generalize to practices outside of interventions specifically geared toward preoperative opioid weaning.

To answer the question of whether decreasing, or even increasing, opioid prescriptions in the weeks to months before surgery is associated with differences in persistent postoperative opioid prescriptions after surgery, Rishel et al.8  examined a retrospective cohort of surgical patients using administrative health claims data. This study cohort comprised patients filling at least 10 opioid prescriptions, or 120 days of opioids, in the year before surgery. Surgeries included a selection of common elective (e.g., total knee arthroplasty) and urgent/emergent (e.g., appendectomy) procedures that were performed between 2004 and 2018. Importantly, a subset of these procedures (e.g., total knee arthroplasty, mastectomy) have been previously associated with increased rates of persistent postsurgical pain.9  The primary outcome was the amount of opioid(s) prescribed between 91 and 365 days after surgery, a time frame commonly associated with varying definitions of subacute to persistent postsurgical pain.9  To examine the effect of preoperative opioid weaning, exposure was defined as patients with a 20% increase or decrease in average daily opioid dose across two sequential time intervals: 365 to 91 days before surgery and 90 to 7 days before surgery.

Surprisingly, Rishel et al.8  found that after adjusting for confounding effects, either a 20% decrease or increase in opioids prescribed in the 90 days before surgery was linked to a lower rate that any opioids would be prescribed 91 to 365 days after surgery when compared with patients with stable opioid prescription rates before surgery. Notably, the absolute reductions were small: a 7% reduction for the group with decreasing preoperative opioid use, and 2.6% for the group with increasing preoperative opioid use, against a reference prevalence of 96.4% of patients with stable preoperative opioid use who continued to fill opioid prescriptions in this postoperative follow-up period. For patients who did receive an opioid prescription in this postoperative time frame, patients with increasing opioid prescriptions 90 days before surgery had a very slightly lower adjusted average daily dose of opioid (a decrease of just 2.2 oral morphine milligram equivalents against a reference adjusted average daily dose of 46.5 oral morphine milligram equivalents in the opioid-stable group) 91 to 365 days after surgery. Secondary analyses did not detect differences in the rate of postoperative adverse events, healthcare costs, or the number of days of postoperative hospitalization across the three groups of preoperative opioid trajectories.

Among other points of their methodology, Rishel et al.8  should be particularly commended for their robust approach to sensitivity analyses used throughout their study; their careful consideration strengthens the support of their results and anticipates questions on whether select assumptions (e.g., the definition of chronic opioid use) could have altered the findings.

As with many great research reports, these findings raise several interesting questions. First, how do we explain the decrease in longer-term opioid prescriptions for both preoperative opioid escalators and de-escalators? Without insight into the driving factors leading to opioid escalation or de-escalation before surgery, it remains impossible to define mechanisms explaining this linkage. Such conjectures become more challenging when one considers that between 2004 and 2018, our understanding of the dangers of perioperative opioids became much more widespread, as did alternative analgesic approaches. In one potential explanation, the authors posit that for patients with increasing preoperative opioid use, worsening pain may have driven increasing opioid use and a decision for surgery that then ameliorated the underlying pain generator. They do note, however, that the observed results held for nonelective procedures, whereby intentional reduction of opioids in preparation for surgery may not have been feasible. It may be that it is not the increase or decrease itself that is relevant, but rather the responsive practice dynamic that drove a minimum-necessary approach to opioid prescription. It is also possible that for subsets of both escalators and de-escalators, different motivations nevertheless lead to the same use of various behavioral, interventional, or multimodal analgesic strategies that influenced postoperative opioid prescriptions. In such cases, patients on a stable opioid regimen may not have had similar incentives to use such analgesic adjuncts. Given these and other possible explanations for the observed findings, it is important to consider that the health claims data used in this analysis originated with patient members of commercial and Medicare Advantage health plans; this may pose limitations in generalizability for other socioeconomic groups in the United States.

Relatedly, this article highlights opportunities to better understand which conditions initiated an analgesic prescription. Rishel et al.8  wisely selected both elective and emergent procedures, as well as procedures associated and not associated with chronic preoperative and postoperative pain. Despite extensive sensitivity analyses, no major differences emerged between these procedure groups. Notably, 8.6% of patients on long-term preoperative opioids had cessation of opioid prescriptions 91 to 365 days after surgery. These findings comport with those of Jivraj et al.,10  who found in a cohort of chronic opioid users that surgery was associated with increased likelihood of opioid discontinuation, especially if the mean preoperative opioid dose was less than 90 morphine milligram equivalents, and that discontinuation was greater for surgical versus medical patients.10  It is plausible that for some of these patients, the surgery directly addressed the underlying pain generator and obviated the need for continued opioid therapy. However, such presumptions may be called into question if, for example, the opioids were prescribed for back pain and yet the patient underwent a laparoscopic appendectomy for appendicitis. Such discernments are simply not feasible with contemporary data commonly used in pharmacoepidemiology. It is worth highlighting that opioid consumption is not the same as opioid prescription, that previous works highlighting the number of opioids prescribed after surgery can substantially exceed the amount consumed, and that increased prescriptions are associated with increased consumption.11 

This research project also highlights more systematic opportunities in how health data are collected and managed. Following established approaches to pharmacoepidemiology, Rishel et al.8  carefully define exposures, which in this case are opioid trends (escalating, de-escalating, stable). In effect, these trends represent decisions, or perhaps a series of decisions over time, that establish the observed trends. But what drove these decisions? Was there a particular state change that led the prescribers to modify their analgesic approach? Without this sequence of state–action–outcome, it becomes difficult to understand how we might more fully incorporate these results into our day-to-day decision-making. Such opportunities are systematic throughout health outcomes research. While causal inference and related methods can plausibly address some of these shortcomings, they remain constrained by the features and organization of data commonly found in outcomes research.

Another opportunity relates to how outcomes surrounding pain are collected in both clinical and research constructs. While this study captured information pertaining to opioid prescriptions, it is reasonable to presume that such opioids were most likely prescribed due to increased pain intensity. After surgery, pain intensity absent context provides little support for clinical decisions; a pain intensity rating of 8 out of 10 may be reassuring (at least, from an analgesic titration perspective) as a postoperative patient continues to lap the ward at an 8-min mile pace, yet 0 out of 10 would be quite concerning in a patient with respiratory compromise. Similarly, data on opioid use (whether prescription or administered doses) absent context on pain intensity, pain quality, and normalized indices of patient function provide only limited insight into quality of recovery.

In summary, the report by Rishel et al.8  suggests that regarding preoperative opioid therapy, a change in use in any direction may be associated with small improvements in postoperative opioid requirements, at least as measured by opioids prescribed. We look forward to learning more about the potential clinical relevance of these findings, as well as the practice patterns that could motivate such trends in both perioperative opioid–related exposures and outcomes.

Supported by the Donn M. Dennis, M.D., Professorship in Anesthetic Innovation, University of Florida College of Medicine, Gainesville, Florida.

The author is not supported by, nor maintains any financial interest in, any commercial activity that may be associated with the topic of this article.

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