Health Care Burden Associated With Adolescent Prolonged Opioid Use After Surgery
Anesthesia Analgesia
Submitted January 2023 by Dr David Sainsbury
Read by 273 Journal Watch subscribers
Summary
This was a retrospective cohort study of opioid-naïve patients aged 12-21 undergoing surgery. The study used insurance claim data to examine the healthcare usage of the patients and the association with prolonged opioid use after surgery (POUS). POUS was defined as one or more opioid prescriptions dispensed between 91 and 180 days
after the incident surgical procedure and the association with health care utilisation up to 730 days after the surgical encounter. The study found that the patients in the POUS group had greater health care utilisation including LOS, inpatient, outpatient and emergency department visits. This was associated with a mean increase in cost of US$4604.
Discussion
The authors’ conclusions that POUS is associated with increased health care utilisation is probably correct. Despite being a retrospective study, its major strength, like many similar studies, is the sheer wealth of data that the US insurance providers collect. This included 126,338 patients over the course of 16 years with each patient ‘followed up’ for 2 years post-procedure. The authors highlighted that the POUS cohort are more complex at baseline with
more pain problems, mental health challenges and chronic illnesses. These are a group of patients who are likely to struggle with any surgical procedure although the increased healthcare use remained after taking these baseline characteristics into consideration.
There is a dearth of procedural information and post-procedure clinical information such as whether the patients were developing a persistent post-surgical pain state for which they felt opioid use was appropriate. There have been multiple studies in the US looking at how exposure to opioids even for routine procedures can lead on to chronic opioid use. This has variably been called chronic or persistent opioid use seemingly to facilitate research in this area. However, these terms can be problematic as they do not represent a clinical entity.
In this study, the lack of context also means we have no idea what POUS and the increased healthcare usage actually represents. This failure to identify modifiable patient and system factors means this information is of limited use for most clinicians other than to serve as a reminder that ‘normal’ peri-operative exposure to opioids in our vulnerable young patients can lead to aberrant opioid use.
It is also worth noting the massive amount of opioid these POUS adolescents and young adults were prescribed; across the study there was a mean of 20 days’ supply with a mean morphine equivalent of nearly 1100 mg. It would have been interesting to see how those prescribing practices might have contributed to POUS and to take the opportunity to remind prescribers of their responsibility to ensure good opioid stewardship.
