New Persistent Opioid Use After Surgery: A Risk Factor for Opioid Use Disorder?

Drug overdose deaths in the US recently reached a record level of 93,000 in 2020.1 Recent estimates suggest that 1.6 million Americans have an opioid use disorder (OUD) and 10 million misuse opioids. While the alarming rise in deaths is mostly due to illicit fentanyl, inappropriate surgical prescribing is widely recognized as a contributor to inappropriate opioid use for several reasons.2 First, over-prescribing remains common, despite recent efforts to mitigate excess post-discharge prescribing and reduce opioid use after surgery.3 Moreover, unused opioids are infrequently disposed, creating a reservoir of pills available for unintended use. Finally, surgery remains the first time many patients take prescription opioids, which exposes patients to risk of long-term use. As such, surgeons have a responsibility to prevent poor opioid-related outcomes, particularly among those who are most vulnerable. Here, we outline the clinical complication of new persistent opioid use, describe its relationship with opioid use disorder, and provide context on implications for surgical care. New Persistent Opioid Use After Surgery Roughly 60% of individuals presenting for surgery are opioid-naïve. Compared to patients with prior opioid exposure, opioid-naïve patients have fewer comorbidities, less pain, and quicker recovery after surgery, which leads to fewer readmissions, respiratory-related complications, and a lower risk of perioperative mortality.4,5 However, opioid-naive patients still encounter risks of poor outcomes as well. Although the majority of patients require opioids after most types of surgical procedures for only a few days, if at all, up to 10% of opioid-naïve patients prescribed opioids after surgery continue to fill those prescriptions beyond 3 months, a commonly accepted time period in which resolution of acute surgical pain is anticipated to occur. This new persistent opioid use occurs when continuation of opioid use takes place beyond the immediate postoperative period among previously opioid-naïve patients and represents use over a longer period than intended. However, not all patients who develop new persistent opioid use are the same.6 New persistent opioid use after surgery likely represents a constellation of many different phenomena, which is difficult to discern without additional context from the patient. Moreover, the mechanisms for new persistent opioid use after surgery have important implications for postoperative care and transitions in care settings. For example, patients may have persistent pain related to the surgical procedure and take opioids as prescribed without negative consequences, but others may take opioids to treat non-surgical pain. Similarly, some patients may continue taking opioid prescriptions for non-pain symptom management, such as disordered sleep or changes in their mood. Nonmedical use occurs when patients take opioids in ways other than as prescribed by a physician, and misuse behaviors range from simply misunderstanding how to take medications as prescribed to more concerning activity. An even smaller proportion may develop addiction and be at risk for overdose. New Persistent Use: One Component of Opioid Use Disorder? Opioid use disorder occurs when patients experience clinically significant impairment or distress from a problematic pattern of opioid use. The clinical entity opioid use disorder is preferred over previous phrasing such as opioid dependence or opioid abuse, given the imprecision and stigma associated with those terms. Eleven features characterize the clinical phenotype for OUD, and at least two of the eleven criteria should be present within a 12-month period to establish an OUD diagnosis. In this context, does new persistent opioid use align with criteria for OUD? The first criteria describe opioids “often taken in larger amounts or over a longer period than was intended”.7 Among opioid-naïve patients presenting to surgery, opioid use beyond 30 days after surgery represents a duration longer than intended for most operations. Nonetheless, prolonged postoperative use has only recently come under scrutiny, and important gaps in knowledge exist regarding the risk factors for new persistent use. One concern is that opioid exposure from surgical prescribing may reveal a previously unrecognized predilection for addiction. While this is one possibility, other explanations may be similarly plausible. Some patients may experience complications during or after the surgical procedure, leading to prolonged recovery and longer durations of pain than anticipated. Some surgical prescribers may not be familiar with screening options to identify at-risk patients. Moreover, some patients may have greater sensitivity or less tolerance to pain than others. Across diverse healthcare settings, it may be a combination of these and other scenarios, and a better understanding of the circumstances associated with new persistent opioid use after surgery is needed to help guide patients and their caregivers in this space. Implications for Surgical Care New persistent opioid use is particularly challenging to address due to the wide range of phenotypes of opioid use, which is often complicated by transitions in care with respect to pain management and opioid prescribing. These patients likely represent a more complex group who take opioids for a longer period than intended after surgery. As such, for certain patients, new persistent opioid use has the potential to fulfill one diagnostic criteria of OUD. However, a diagnosis of OUD requires at least one other criterion, and the presence of additional criteria indicate greater severity, which has critical implications for intraoperative risk and postoperative recovery. For example, medications for OUD impact perioperative management in different ways due to their varying mechanisms, which include occupying mu receptors for buprenorphine and methadone and antagonizing opioid receptors for naltrexone. On the other hand, some types of medication treatments may not be the most appropriate first step to consider for patients with mild OUD. Most surgeons will rely on primary care or mental health providers with buprenorphine waivers or specialists in addiction medicine to help with the assessment, diagnosis, and treatment of patients with OUD. As such, after identifying a patient with new persistent use for non-surgical reasons, the surgeon is likely to need to facilitate a transition in the care of the patient to a provider to provide additional assessment and possible treatment. Surgeons may take several steps to reduce the reliance on opioids within the perioperative pain management of patients. Ensuring adequate treatment of operative and postoperative pain in all patients after discharge from surgery is imperative. Opioid-sparing analgesic regiments that maximize the use of non-opioid drugs such as non-steroidal anti-inflammatory drugs with acetaminophen, when not contraindicated, may help reduce or eliminate the need for prescription opioids and should be emphasized. Patients with persisting pain after surgery, especially those whose pain continues beyond the time period anticipated from the surgical procedure, merit a clinical evaluation and examination prior to the consideration of additional opioid prescriptions. Screening patients for substance use, including opioid misuse and OUD, can help to identify patients in need of more advanced care not only after surgery but across the perioperative period including before surgery. Finally, it is clear that OUD impacts a small but significant portion of the population. Opioid-naïve patients who present for surgery and go on to develop new persistent use of opioids after surgery may be at risk of developing OUD. While the past few years have shown considerable progress in addressing risks from prescription opioids after surgery, the next and more challenging issue is how to approach more complex patients who present with new persistent use of opioids after surgery.