Pain is an unavoidable part of the healing process after surgery. Yet the current opioid crisis has made the standard prescribing practices for painkillers loaded with risk.
A new study from Michigan Medicine (U-M) could help clinicians navigate this risk by identifying which patients may be more likely to continue using opioids after their immediate recovery period.
“There is not much research on which surgical patients require more or less opioids, despite a push in the field for personalized medicine,” said first author Daniel Larach, M.D., M.T.R., M.A., a resident at U-M at the time of the study and now an assistant professor of clinical anesthesiology at the University of Southern California.
“Often with postoperative opioid prescribing, personalization falls by the wayside, with surgeons using the same amounts for every person receiving a certain procedure.”
The findings are published in the Annals of Surgery.
For the study, the research team evaluated the data of more than 1,000 people undergoing an elective hysterectomy, thoracic surgery, or a total knee or hip replacement. Before their operations, each patient provided demographic information and completed several screening questionnaires.
The patients were given scores measuring their degree of depression, anxiety, fatigue, sleep disturbance, physical function, as well as the severity of their overall and surgical site pain. The researchers also measured how many pills were prescribed to each patient.
The patients were then contacted one month following the surgery to assess how many opioid pills they had consumed.
“We found that anxiety is linked with more opioid use, which is disheartening to see but also heartening in the sense that this is something we could potentially target,” said Larach.
Other patient factors linked to increased opioid use included younger age, non-white race, no college degree, alcohol and tobacco use, and sleep disturbance.
Chad Brummett, M.D., associate professor of anesthesiology and director of anesthesia clinical research and pain research, said people may be knowingly or unknowingly medicating for other conditions.
“The only thing we’re giving them is opioids and we’re not giving them alternatives or other options,” he said. For example, patients with high anxiety around the time of surgery could be offered behavioral care or other non-opioid medications for anxiety and resulting pain.
Brummett also noted that the study found overprescription of opioids for all surgical procedures and a link between the prescription size and use.
“I think it is striking that you see once again that the more you prescribe, the more patients take, even after adjusting for all of these other risk factors,” Brummett said.
The team noted that right-sizing prescriptions through initiatives such as the Michigan Opioid Prescribing Engagement Network (OPEN), which provides recommendations for prescription amounts for various medical procedures, is a critical first step.
But, they say, this step should be followed by more research into specific patient factors that can be addressed in other ways.
“We are asking surgeons to learn about and think about pain and behavioral health in ways that we have not previously done. It will require an open mind,” said Brummett.