Prescribing opioids after minor surgery can lead to long-term use

About 7% of patients recovering from minor surgical procedures are prescribed opioids within a week, and more than 10% of these patients are still taking the painkillers a year later.

The findings, published March 12 inArchives of Internal Medicine, come amid calls to curb unnecessary prescribing of opioids that are often misused and diverted. The painkillers were linked to 14,800 overdose deaths in the U.S. in 2008 — nearly four times the 1999 death toll of 4,000 — according to the Centers for Disease Control and Prevention’s Nov. 4, 2011, Morbidity and Mortality Weekly Report. Sales of painkillers also have skyrocketed, rising from 1.8 kg per 10,000 people in 1999 to 7.1 kg per 10,000 people in 2010.

“It’s hard to get people off these medicines,” said Chaim M. Bell, MD, PhD, the study’s senior author and assistant professor in the Dept. of Medicine at the University of Toronto. “The easier thing to prevent is initiation, and there are times when these are initiated when they might not need to be. That’s the reason we looked at this particular area. Potentially, something can be done about it.”

Dr. Bell and his co-authors examined the records of nearly 400,000 patients 66 and older in Ontario, Canada, who had not been prescribed opioids during the year before minor procedures such as cataract surgery, varicose vein stripping and transurethral resection of the prostate.

The patients who were prescribed opioids within a week of surgery were 44% likelier to be using the medications a year later than the patients who did not get opioids during recovery, the study said. The most frequently prescribed opioid was codeine, ordered 93.4% of the time. Oxycodone was prescribed for 5.4% of patients. After a year, the proportion of patients taking oxycodone had risen to 15.9%.

Dr. Bell, a hospitalist at St. Michael’s Hospital in Toronto, suggested that physicians and hospitals re-examine their standardized medication order sets to avoid prescribing opioids for less-painful procedures. Other physicians advised that primary care doctors scrutinize patients asking for refills for the opioids they were given after surgery.

Comprehensive follow-up is key

After 90 days, opioid therapy “is often prolonged and may be a self-perpetuating or lifelong therapy,” according to a commentary also published in the March 12 Archives.

“At that point, you need to do a more comprehensive evaluation to see what potential psychiatric comorbidities are there, things like depression and posttraumatic stress disorder, ongoing substance abuse or a history of past substance abuse,” said Mark D. Sullivan, MD, PhD, co-author of the commentary and professor of psychiatry and behavioral science at the University of Washington School of Medicine in Seattle.

“You need to start including other modes of treatment besides opioids, such as physical therapy and perhaps a rehabilitation medicine consultation. You should be looking at pain and patient functioning with a bit broader point of view than the prescription pad,” he said.

Primary care physicians also should consider referring to psychologists who specialize in helping patients with chronic pain understand and better manage their condition while keeping opioid use to a minimum, said Beth D. Darnall, PhD, assistant professor in the Dept. of Anesthesiology and Perioperative Medicine at Oregon Health & Science University in Portland. She co-wrote another commentary in the same issue of the journal that examined the effects of long-term opioid therapy in female patients.

Continued use of opioids so long after minor surgery “should create concern and should point people to the need for constant reassessment,” said Norman Marcus, MD, medical director of the Norman Marcus Pain Institute , a New York City clinic that specializes in treating back, neck and shoulder pain.

“One of the problems in medicine in general is that patients tend to get into a pattern of using medicines because someone gave it to them in the past, and they just keep taking it,” Dr. Marcus said. “Doctors should be constantly reassessing the downside to any medicine that one takes.”