Opioid Use Does Not Impart Higher In-Hospital Mortality for Cardiac Surgery Patients

US clinicians have seen a surge in patients who persistently use or are dependent on opioids in recent years, and while prolonged opioid use has been linked to higher cardiovascular risk, it should not be the basis for denying patients cardiac surgery, new research shows.

An analysis of data from more than 5.7 million individuals, published online yesterday in JAMA Cardiology, demonstrates no difference in rates of in-hospital mortality based on opioid use disorder (OUD) among patients undergoing cardiac surgery such as CABG, valve surgery, or aortic surgery. However, patients with OUD did see an increase in major complications.

“The impetus for this study really was a handful of patients that were referred to us at the Cleveland Clinic after having been denied surgery elsewhere because of their opioid use. And it dawned on us that . . . there are no large-volume trials or reviews of this patient population despite the fact that it’s an increasing problem,” Edward G. Soltesz, MD (Cleveland Clinic Foundation, OH), senior author of the study, told TCTMD. As such, the investigators wanted to quantify mortality and other risks of cardiac surgery in this group, as well as the cost of care.

OUD is defined as a persistent use of opioids for longer than a period of 90 days, Soltesz said. “What we’ve now begun to understand is the chronic use of opioids, in and of itself, is not good. Patients should be transitioned to some other form of multimodal pain management.”

Approximately 2 million people in the United States meet the criteria for OUD, with an estimated economic burden of nearly $79 billion each year, lead investigator Krish C. Dewan, BS (Cleveland Clinic Foundation), and colleagues report.

Complications, Length of Stay, Cost

For their analysis, Dewan et al gathered information from the National Inpatient Sample on 5,718,552 patients (mean age 47.7 years; 68% men) who underwent cardiac surgery between 1998 and 2013.

Only 0.2% of patients (n = 11,359) within this group had been diagnosed with OUD, though prevalence increased eightfold over the 15-year time span, from 0.6% in 1998 to 0.54% in 2013. Patients with OUD were nearly 20 years younger on average; were more often male, black, or Hispanic; and tended to have a lower median income. Compared with those without OUD, they also were far more likely to be insured or a Medicare beneficiary (48.6% vs 7.7%; P < 0.001). Valve and aortic surgery predominated in the OUD group, while the non-OUD group mainly underwent CABG.

In a propensity-matched analysis of 11,202 pairs, mortality did not differ between patients with versus without OUD. However, OUD was associated with significantly more in-hospital complications, longer stays, and higher per-patient cost. Additionally, patients who had been diagnosed with OUD were more likely to be discharged to a long-term skilled inpatient facility rather than to home (OR 1.56; 95% CI, 1.47-1.72).

Cardiac Surgery Outcomes and Cost: Propensity-Matched Analysis

Individuals with OUD were at a significantly higher risk of mortality if they were black or Hispanic; had arrhythmia, heart failure, coagulopathy, or endocarditis; or were located in the Western United States. Hospitals with a yearly volume of at least 200 cardiac surgeries had a 35% reduced risk of mortality when treating patients with OUD than did lower-volume hospitals.

“Patients should not be denied surgery because of OUD status but should be carefully monitored postoperatively for complications,” the researchers conclude.

OUD is often accompanied by comorbidities that would affect the process of recovery, whether that’s coming off the ventilator or mobilizing after surgery, Soltesz noted to TCTMD. Patients with OUD exhibit some of the same characteristics and outcomes as people who are deemed frail preoperatively, he said.

For patients dealing with OUD and their caregivers, it’s important to begin thinking of how to stop chronic use under a physician’s care and to possibly seek out a higher-volume hospital when undergoing cardiac surgery, Soltesz advised.

For clinicians, he said, it’s important that they be aware and ask patients the right questions ahead of surgery, to identify who has OUD. This information factors into how the risks and benefits of a procedure are weighed, Soltesz said. “Clearly if you have someone with significant chronic lung disease and you find out they have an opioid use disorder and you’re planning coronary artery bypass, maybe you should look at a PCI [and] putting a stent in. That may be lower risk.”