American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Treating pain safely in surgical patients: Opioids, part 2

OCTOBER 25, 2017
Clinical Congress Daily Highlights, Wednesday Second Edition

Addressing the pain needs of surgical patients presents a dilemma with each prescription: How can we treat patients’ pain without putting them at risk for opioid abuse? This problem is all the more difficult because existing guidelines often do not adequately address safe and effective post-discharge dispensation.

In this second of two stories on studies related to post-surgical pain relief and opioid abuse, we summarize four studies that bring new insights to the subject:

A study led by Gabriel Brat, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, found that the duration of opioid use post-surgery was a stronger indicator of potential abuse than the dosage of the prescription. Looking at a de-identified administrative and pharmacy database of 37.6 million commercially insured patients between 2008 and 2016, the study considered 568,524 patients who received post-operative opioids; an abuse code was identified in 5,889 of them. The researchers found that, after adjustment, each additional week of opioid exposure was associated with an increase in abuse of 21.6 percent.

A second study led by Calista Harbaugh, MD, of the University of Michigan in Ann Arbor found concerning rates of high-risk prescribing and persistent opioid use among adolescents. Looking at prescription fills among 183,592 postoperative patients from 13 to 21 years old who had never taken opioids before, the researchers found that 88,638 had filled an opioid prescription. Within that group, 4.8 percent filled prescriptions beyond 90 days from surgery and 11.8 percent of the prescriptions bore hallmarks of high-risk prescribing. Older children and those with depression or anxiety were more likely to receive high-risk prescriptions. The findings indicate that efforts need to be made to identify best practices for safe postoperative prescribing for children and adolescents.

“New Persistent Opioid Use after Bariatric Surgery,” led by Sanjay Mohanty, MD, of the University of Michigan in Ann Arbor, found that patients using opioids for the first time after undergoing bariatric surgery develop much higher rates of persistent use compared to other general surgical patients. Patients undergoing bariatric surgery may be particularly vulnerable to opioid dependence due to chronic knee and back pain associated with morbid obesity. Nearly 10 percent of opioid naïve patients reported persistent opioid use one year after surgery, a 60 percent higher rate compared to general surgical patients, according to the study. Overall, 27 percent of post-bariatric surgery patients reported opioid use one year following bariatric surgery. Given the elevated risk of cross-addiction to alcohol and illicit drugs in these patients, the authors conclude, providers should pay special attention to opioid use in postoperative bariatric surgery patients.

Finally, in one type of bariatric procedure, laparoscopic Roux-en-Y gastric bypass (LRYGB), researchers found that restricted opioid usage is feasible in conjunction with a one-day fast-track protocol. A study of 54 patients by Ioannis Raftopoulos, MD, FACS, of Holyoke Medical Center, Holyoke, CT, and colleagues documented a higher percentage of revisional LRYGB among opioid-restricted patients, but found no other significant differences compared with 820 postoperative patients on unrestricted opioids.

Additional Information:
These Scientific Forum presentations occurred at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA.  Program, webcast and audio information is available online at

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