Opioid Use Still Too High Among Cardiac Surgery Patients

Almost one-tenth of opioid-naïve patients who undergo cardiac surgery will continue to use opioids for at least 90 days, with discharge dosing directly tied to long-term use, according to a new analysis.

The toll of the opioid crisis in recent years has driven the healthcare community to rethink prescribing patterns in order to minimize the likelihood of addiction in patients who need pain management. Yet a Medicare claims study published last year showed that as many as one in eight cardiothoracic surgery patients from 2009 to 2015 continued to take opioids longer than necessary.

Enhanced recovery after surgery (ERAS) protocols that include opioid minimization are gradually being embraced by cardiothoracic surgeons, but challenges related to patient education and documentation of the total amount of opioids given to patients in the hospital remain.

“Cardiothoracic surgeons, cardiologists, primary care clinicians, and advanced practitioners should all enact evidence-based protocols to identify high-risk patients for persistent use and minimize opioid prescriptions postoperatively with multimodal analgesia techniques,” write Chase R. Brown, MD, MSHP (Hospital of the University of Pennsylvania, Philadelphia), and colleagues.

Now that we are all in agreement that it's at least 10% of patients at very high risk of long-term narcotic addition after cardiac surgery, we need to figure out preventive strategies. Daniel T. Engelman

“As we’ve learned more about the opioid epidemic, one of the things that was understood early on was where it all starts,” senior author Nimesh Desai, MD, PhD (Hospital of the University of Pennsylvania), told TCTMD. “One of the things that we didn’t have a good sense of was how that relates to cardiac surgery. Cardiac surgery is still done generally with fairly large invasive operations with large incisions and it often requires going in through the breastbone, so we do use a fair amount of opioids for pain management after surgery. What we didn’t really know was what happens to patients when they're exposed to opioids over the long run.”

Daniel T. Engelman, MD (Baystate Medical Center, Springfield, MA), who serves as president of the ERAS Cardiac Society, who was not involved in the study, told TCTMD he is “concerned that the data such as within this paper is not known widely among the multidisciplinary teams that take care of our cardiac surgical patients and that we need to not only share the problem, which this points out, but share some solutions. . . . Now that we are all in agreement that it's at least 10% of patients at very high risk of long-term narcotic addition after cardiac surgery, we need to figure out preventive strategies.”

Discharge OME Linked with Dependence

For the study, published online June 17, 2020, ahead of print in JAMA Cardiology, the researchers retrospectively included 35,817 patients from a national administrative claims database who underwent CABG (n = 25,673) or heart valve procedures (n = 10,144) between 2004 and 2016. None of the included patients had taken opioids within 180 days before their surgery and all filled an opioid prescription within 14 days after their procedure.

The researchers converted all patients’ opioid doses to oral morphine equivalents (OMEs) in order to standardize each opioid drug to an equianalgesic dosage using morphine as a reference. Opioid dependence—the primary outcome defined as refilling an opioid prescription 90 to 180 days after surgery—was seen overall in 9.6% of patients. Broken down by surgery, those who underwent heart valve procedures were less likely than patients who had CABG to refill opioid prescriptions between 90 and 180 days (8.1% vs 10.2%; adjusted OR 0.78; 95% CI 0.70-0.86). CABG patients were also more likely to refill their prescriptions within 180 to 270 days (8.9% vs 7.2%; P < 0.001).

Other risk factors for developing new persistent opioid use were diverse, with a prior history of chronic pain nearly tripling the likelihood of persistent use.

Predictors of New Opioid Use

Lastly, patients who were prescribed more than the median 300 mg OME value (approximately 40 tablets of oxycodone 5mg) at discharge were at an increased, dose-dependent risk of developing new persistent opioid use.

Desai said the overall rate of new persistent opioid use observed in this study was higher than expected. This could be due to the fact that this was the first study to take “a more representative sample of cardiac surgery patients because it was done using an insurance database,” he suggested.

As for what to do about it, Desai said “we’re already down the pathway of trying to really make a difference in decreasing opioid use.” Cardiac surgeons have begun switching to more minimally invasive procedures, using more long-term local anesthetic agents to decrease early postoperative pain, and stressing early extubation and early mobilization, he noted. “All of [these] we think decreases the need for pain medicine afterwards. And most importantly, we’re just prescribing less pain medicine at discharge.”

Patient education and awareness have also played a role in the decrease of opioid use following cardiac surgery, according to Desai. “The patients themselves, after all that we’ve seen in the news about opioids, do not want to be on opioids,” he said. “That’s probably one of the biggest changes that we've seen is at the patient level.”

Preventing a Lifelong Problem

In an accompanying editorial, Steven Farmer, MD, PhD (Centers for Medicare & Medicaid Services, Baltimore, MD), and colleagues write that “three issues lie at the core of the challenge highlighted by the study by Brown et al: the need to educate clinicians about the magnitude of the risk, the need for more comprehensive risk factor screening for opioid dependency, and the need for lower-risk pain management options.”

The patients themselves, after all that we’ve seen in the news about opioids, do not want to be on opioids. Nimesh Desai

They recommend increased use of the Opioid Risk Tool, specialized physician documentation of personal or family history of substance use or psychological disorders, and opioid-sparing pain management strategies for high-risk patients.

“All parties need to come together to meet this challenge. In 1854, John Snow, MD, was credited with containing a cholera epidemic in London, England, by recommending removal of the pump handle from a contaminated well,” Farmer and colleagues conclude. “More judicious use of postoperative opioids could narrow the current-day opioid epidemic by minimizing opioid exposure in the first place.”

For Engelman, having these numbers helps cement the need for change. “We know there's an opioid crisis and we know that cardiac surgical patients fall into that population of patients at risk for new persistent opioid use, but we have not been able to consistently demonstrate either the percentages, the risk factors, or possible means to decrease that new persistent opioid use,” Engelman said. “This paper is one more step in that direction.”

Prescribing opioids following cardiac surgery used to be done on a much more casual basis, with many patients being sent home with “just in case prescriptions,” he explained. But creating dependency on opioids following surgery is “not just a 3- to 6-month problem. This could be a 1- to 3-year or potentially lifelong problem now for this patient population.”

The most meaningful finding from this paper is the relationship between discharge dose and long-term persistent opioid use, Engelman said. “So how do you decrease prescriptions to opioids? It's not as simple as telling your advanced practitioners to write the prescription, but just give less Percocets or oxycodones or whatever. It's not that simple. There's way more pieces to this. This actually begins before surgery.”

This is where an ERAS program that emphasizes patient education and multimodal nonopioid analgesics can really help, he explained. “Before cardiac surgery, the multidisciplinary team needs to meet with the patient and discuss how pain will be controlled after surgery. They need to be told that they're going to have some degree of pain—it needs to be tolerable—and that the risks of making the pain zero outweigh the risk of having just a tolerable amount of pain.”

In addition, Engelman said his institution employs a proprietary app embedded in the electronic medical record to track patient OME dose. “It allows us to de-escalate it, to benchmark it, and to make sure that by the time the patient is discharged, they are on the lowest possible OME dose, which this manuscript now has shown correlates with the least possible likelihood of long-term new persistent opioid dependence,” he said. “About half our patients go home on no opioids. We'd like to make that zero.”

For physicians without access to such an app yet, he recommends having a pharmacist come on rounds to help calculate patient OME dose and suggest alternative pain management strategies. Engelman also cautioned against physicians providing “just in case” opioid prescriptions following discharge even if they think they are making patients’ lives easier by doing so. “What happens to those scripts? Potentially nothing good,” he said.

Desai said the next logical step for research "is to really see what the impact of the ERAS protocols are on opioid use. . . . It would be interesting to measure where this has gone in the current era because this data obviously goes back to 2004 to 2016 and I think we really started to get on top of this problem in 2016 to 2017.”

All of this discussion has taken on a new dimension during the COVID-19 pandemic, which has changed everything in the cardiac surgery space, Engelman observed. “And we’re not going back, at least not in the next few years. We're going to have much more emphasis on evidence-based standardized best practices, such as ERAS protocols, that everybody just can't do their own thing. We have to figure out what the best possible practice is and reproduce it over and over again in order to get the patients out of the hospital in the least amount of time, in a safe manner, and not have them readmitted.”

Achieving proper pain control in order to avoid patients coming back to the office will be key, and virtual visits will be vital in this endeavor, he said. “We used to just sign everybody up to return to the office in 2 weeks after discharge for a checkup. Those days are over. I'm hoping that for the better instead we'll have one of our advanced practitioners or our nurses call the patients within 48 hours of discharge and actually have a face-to-face teleconference with them,” Engelman said. “My sense is that despite the difficulties we're having with the pandemic, this actually may be a positive for standardizing evidence-based practice at keeping a closer watch on our patients to prevent that dreaded readmission.”

COVID-19 and the measures taken worldwide to contain it are boosting the number of opioid deaths, relapses, and new opioid addictions, experts warn. A recent editorial in the American Journal of Managed Care called COVID-19 an “unanticipated haven for the already formidable opioid epidemic.