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OPEN Works to Monitor Trends in Opioid Prescribing and Persistent Use After Surgery

Dec 13, 2024

Postoperative opioid prescribing is meant to address moderate-to-severe pain that can’t be controlled by over-the-counter medications. Yet, prescriptions after surgery can pose unintended risks of prolonged use.1 Several recent studies suggest that inappropriate postoperative opioid prescribing is correlated with increased opioid use, as well as new persistent use among opioid naive patients – defined as continuation of filling opioid prescriptions months after surgery for people who were not exposed to opioids prior to a procedure.2-7  

While acute care opioid prescribing has declined over the past few years, many patients take opioids to manage chronic pain.8 Patients who are on long-term or chronic opioid therapy plans are an understudied population when it comes to addressing the opioid epidemic.9,10 Of course, there are additional factors to consider that can complicate postoperative pain management plans, such as varying opioid tolerances from patient to patient.11

The Overdose Prevention Engagement Network (OPEN) has nearly 10 years of experience in developing transformative, evidence-based solutions to reduce harm and stigma surrounding substance use. Since OPENs launch in 2016, many hours have gone into creating appropriate opioid prescribing recommendations and finding ways to get them into the hands of healthcare professionals across Michigan for starting a discussion about postoperative pain management with their patients. Over the past few years, OPEN has identified several trends in opioid prescribing and persistent use of opioids after surgery. 

Trends in Opioid Prescribing and New Persistent Use in the United States

Over 980,000 opioid-naive patients who underwent one of seventeen common surgical procedures between 2013 and 2021 were examined using multi-payer claims data from the Health Care Cost Institute (HCCI). Findings suggest that opioid stewardship practices had favorable effects on opioid prescribing and new persistent use.1 Patients were excluded from the study if they were under 18 years of age, discharged to a secondary facility, underwent an additional procedure within six months, and/or did not have continuous insurance twelve months prior and six months following their surgery. 

Researchers found that the average opioid prescription size decreased from 282 Oral Morphine Equivalents (OME) to 164 OME, and that persistent use decreased from 2.7% in 2013 to 1.1% in 2021. Additionally, for every 10 tablets of 5 mg oxycodone increase in the initial prescription size, the odds of developing new persistent use increased by 6%.

Findings should be considered next to this study’s limitations, including that this study relies on administrative claims data from a privately insured population ,which lack clinical granularity. While this study cannot demonstrate causality, findings suggest that reductions in both initial opioid prescription size and new persistent use after surgery may be attributed to public health efforts on improving opioid stewardship.

Medicaid Insurance Predicts Increased Postoperative Care Encounters Among Patients on Long-Term Opioid Therapy

A second study analyzed individuals who received a supply of opioids for greater than 120 days or 10 or more opioid prescriptions in the year prior to their surgery. Researchers looked for unplanned care encounters, meaning an emergency department visit or unplanned readmission inside 30 days of discharge from surgery. Inclusion criteria for this study included patients having either Medicaid or private insurance, must have undergone abdominopelvic surgery, and must have had their surgery between 2017 and 2021. 

Of 1,212 patients on long-term opioid therapy prior to surgery, 45.6% had Medicaid, and 54.4% had private insurance. The chance of an unplanned encounter was 4.5% higher among Medicaid patients. Overall, one eighth of the patients met criteria for a postoperative unplanned care encounter within 30 days.12 These results are likely multifactorial, as differences in insurance status can reflect disparities in underlying social determinants of health and suggest the need for more postoperative care pathways.

Frailty Status, Not Just Age, is Associated With Postoperative Opioid Consumption

A third study examining frailty status found that it’s associated with increased opioid consumption after common operations. Frailty is a process characterized by decreased physiologic reserve and resistance to stressors and has emerged as a distinct risk factor in addition to chronological aging.13

This retrospective analysis of 34,854 opioid-naive adult patients undergoing common surgical procedures in Michigan between Nov 6, 2017, and Feb 28, 2021, was conducted. Analysis found 10,596 patients had a frailty score of <1, which is associated with decreased patient-reported opioid consumption.14 Additionally, 3,635 patients had a score of >1, indicating an increase in patient-reported opioid consumption.14

Across these patients, the mean number of opioids prescribed was 80.2 OME. The mean amount of prescribed opioids for a frailty score of 0 was 78.6 OME; a frailty score of 1 was 81.9 OME; and a frailty score of equal or greater than 2 was 83.8 OME. The mean patient reported opioid consumption was 35.2 OMEs, and the mean of opioid consumption for frailty score of zero was 35.4, a frailty score of one was 33.7 and greater than or equal to 2 was 38.4.

Findings suggest that frailty status is associated with increased opioid consumption after common operations and suggests that future prescribing guidelines and studies should consider this marker when reviewing opioid consumption data. 

New Trends in Opioid Prescribing

These three studies demonstrate that in the current state of the opioid crisis, new trends are arising; a decrease in persistent opioid use that suggests the favorable effects of opioid stewardship, an increase in unplanned healthcare encounters for those with long term opioid use with Medicaid over private insurance, and a higher frailty score is associated with increased opioid consumption.

Despite opioid prescriptions decreasing overall, there are still populations that are seeing an increase in use. Underprivileged or people identifying as part of a minority group have still seen an increase in use. 

OPEN provides resources and services to assist healthcare professionals and community members in progressing through the current opioid crisis. Healthcare professionals can schedule a consultation with one of our on-call providers to learn more about prescribing MOUD or assisting with postoperative pain management. Community members can apply to receive SAFE Storage + Disposal Kits to promote safe storage and disposal in our communities.

While the landscape of the current opioid crisis is ever changing, these new trends give us insight in how we can continue to find solutions, reduce stigma, and provide life-changing resources. 

References:

  1. Luby, A. O., Alessio-Bilowus, D., Hu, H. M., Brummett, C. M., Waljee, J. F., & Bicket, M. C. (2024). Trends in opioid prescribing and new persistent opioid use after surgery in the United States. Annals of Surgery. https://doi.org/10.1097/sla.0000000000006461 
  2.  Brummett, C. M., Waljee, J. F., Goesling, J., Moser, S., Lin, P., Englesbe, M. J., Bohnert, A. S., Kheterpal, S., & Nallamothu, B. K. (2017). New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery, 152(6). https://doi.org/10.1001/jamasurg.2017.0504 
  3. Sun, E. C., Darnall, B. D., Baker, L. C., & Mackey, S. (2016). Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Internal Medicine, 176(9), 1286. https://doi.org/10.1001/jamainternmed.2016.3298 
  4. Brescia, A. A., Waljee, J. F., Hu, H. M., Englesbe, M. J., Brummett, C. M., Lagisetty, P. A., & Lagisetty, K. H. (2019). Impact of prescribing on new persistent opioid use after cardiothoracic surgery. The Annals of Thoracic Surgery, 108(4), 1107–1113. https://doi.org/10.1016/j.athoracsur.2019.06.019 
  5. Howard, R., Brown, C. S., Lai, Y.-L., Gunaseelan, V., Brummett, C. M., Englesbe, M., Waljee, J., & Bicket, M. C. (2022). Postoperative opioid prescribing and new persistent opioid use. Annals of Surgery, 277(6). https://doi.org/10.1097/sla.0000000000005392 
  6. Howard, R., Fry, B., Gunaseelan, V., Lee, J., Waljee, J., Brummett, C., Campbell, D., Seese, E., Englesbe, M., & Vu, J. (2019). Association of Opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surgery, 154(1). https://doi.org/10.1001/jamasurg.2018.4234 
  7. Perez, A. J., Petro, C. C., Higgins, R. M., Huang, L.-C., Phillips, S., Warren, J., Dews, T., & Reinhorn, M. (2022). Predictors of low and high opioid tablet consumption after inguinal hernia repair: An achqc opioid reduction task force analysis. Hernia, 26(6), 1625–1633. https://doi.org/10.1007/s10029-022-02661-3 
  8. Centers for Disease Control and Prevention. (n.d.). Overdose prevention. Centers for Disease Control and Prevention. https://www.cdc.gov/overdose-prevention/?CDC_AAref_Val=https%3A%2F%2Fwww.cdc.gov%2Fopioids%2Fdata%2Fanalysis-resources.html 
  9. Hilliard, P. E., Waljee, J., Moser, S., Metz, L., Mathis, M., Goesling, J., Cron, D., Clauw, D. J., Englesbe, M., Abecasis, G., & Brummett, C. M. (2018). Prevalence of preoperative opioid use and characteristics associated with opioid use among patients presenting for surgery. JAMA Surgery, 153(10), 929. https://doi.org/10.1001/jamasurg.2018.2102 
  10. Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., Dana, T., Bougatsos, C., & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of Internal Medicine, 162(4), 276–286. https://doi.org/10.7326/m14-2559 
  11. Chang, G., Chen, L., & Mao, J. (2007). Opioid tolerance and Hyperalgesia. Medical Clinics of North America, 91(2), 199–211. https://doi.org/10.1016/j.mcna.2006.10.003 
  12. Sharif, L., Zubieta, C. S., Arora, A., Gunaseelan, V., Waljee, J., Bicket, M. C., Englesbe, M., & Brummett, C. M. (2024). Medicaid insurance predicts increased postoperative care encounters among patients on long-term opioid therapy. Annals of Surgery. https://doi.org/10.1097/sla.0000000000006262 
  13. Rodríguez-Mañas, L., Féart, C., Mann, G., Viña, J., Chatterji, S., Chodzko-Zajko, W., Gonzalez-Colaço Harmand, M., Bergman, H., Carcaillon, L., Nicholson, C., Scuteri, A., Sinclair, A., Pelaez, M., Van der Cammen, T., Beland, F., Bickenbach, J., Delamarche, P., Ferrucci, L., Fried, L. P., … Vega, E. (2012). Searching for an operational definition of frailty: A Delphi method based consensus statement. the frailty operative definition-consensus conference project. The Journals of Gerontology: Series A, 68(1), 62–67. https://doi.org/10.1093/gerona/gls119
  14. Latack, K. R., Howard, R., Bicket, M. C., Cooley, S., Gunaseelan, V., Englesbe, M., & Waljee, J. (2024). Frailty status, not just age, is associated with postoperative opioid consumption: A retrospective, population-based analysis. Annals of Surgery Open, 5(4). https://doi.org/10.1097/as9.0000000000000496