Overprescribing Opioids After Surgery for Cancer

New Persistent Opioid Use Among Patients With Cancer After Curative-Intent Surgery

Lee JS, Hu HM, Edelman AL, et al
J Clin Oncol. 2017;35:4042-4049

Study Summary

Patients with cancer undergoing curative-intent therapies may be vulnerable to opioid misuse or dependence because of many reasons, including postoperative pain, psychological distress, pain from adjuvant therapies, and uncoordinated prescribing from multiple providers.

Lee and colleagues sought to define the risk for new persistent opioid use after curative-intent surgery in patients with melanoma, breast, colorectal, lung, esophageal, and hepato-pancreato-biliary/gastric cancers treated with curative surgery between 2010 and 2014.

Using a national data set of insurance claims, they identified more than 68,000 patients, of whom approximately 40,000 were opioid naive, 16,000 were intermittent opioid users, and 12,000 were chronic opioid users prior to surgery.

Among opioid-naive patients, the risk for new persistent opioid use was 10%. One year after surgery, these patients continued filling prescriptions with daily doses similar to those of chronic opioid users, equivalent to 6 tabs per day of 5 mg of hydrocodone. Those receiving adjuvant chemotherapy had modestly higher doses; the covariate-adjusted risk for new persistent opioid use in patients receiving adjuvant chemotherapy was 15%-21% compared with 7%-11% for those who did not receive chemotherapy.

According to the study authors, new persistent opioid use is a common iatrogenic complication in patients with cancer undergoing curative-intent surgery and may be aggravated by receipt of adjuvant chemotherapy.

Viewpoint

This is a timely and provocative study with very clearly defined methods and outcomes. The authors appropriately captured the general anxiety about the unintentional harm caused by the very liberal use of analgesics during cancer therapies. Little is known about the risk for persistent opioid use after curative-intent surgery. This group of investigators from Ann Arbor, Michigan, examined private insurance claims in a retrospective cohort of adult patients treated with curative-intent surgery for a number of solid tumors. With a sample of more than 68,000 patients, they were able to track new persistent opioid use (defined as previously opioid-naive patients who filled an opioid prescription between 90 and 180 days post op) and daily opioid dose during the year following surgery.

Adjuvant chemotherapy was the only variable significantly associated with new persistent opioid use across all disease groups, and radiation only for patients with melanoma and thoracic primaries. Of note, patients who prefilled their opioid prescriptions prior to surgery were at higher risk for becoming persistent users.

The two major findings of this study are that 10% of opioid-naive patients with cancer treated with curative intent develop new persistent opioid use and that adjuvant chemotherapy is a strong risk factor. Oncology clinicians need to play a more active role in counseling patients on postoperative pain as well as that caused by adjuvant therapies (including chemotherapy, hematopoietic growth factors, and oral maintenance endocrine therapies) and work collaboratively in multidisciplinary teams to avoid the potential risks associated with overprescribing.