Author: Bob Kronemyer
Although patients undergoing cardiovascular surgery with persistent opioid use or dependence have roughly the same mortality rate as those without (3.1% vs. 4.0%), the opioid group experiences a higher number of complications overall, a longer hospital length of stay and higher costs, according to a large retrospective population-based cohort study. The study (JAMA Surg2018 Dec 5. [Epub ahead of print]. doi: 10.1001/jamasurg.2018.4608) included more than 5.7 million patients who underwent cardiac surgery in the United States between 1998 and 2013. Propensity matching compared outcomes between the two groups.
The overall incidence of major complications was 67.6% for surgical patients with opioid use disorder (OUD) versus 59.2% for patients without OUD.
“OUD has been a growing problem across the country for several years now,” said principal investigator Edward Soltesz, MD, the surgical director of the Kaufman Center for Heart Failure Treatment and Recovery at the Cleveland Clinic, in Ohio. “Over the course of the 16-year study, we found the proportion of cardiac surgery patients with a history of OUD increased ninefold, from 0.06% of all cases in 1998 to 0.54% of all cases in 2013.”
Among 12 types of complications, rates for all but two—wound infection and gastrointestinal complications—were significantly higher in patients with OUD. “These patients have higher risks of pulmonary embolism, need for mechanical ventilation and prolonged postoperative pain,” Dr. Soltesz said.
The reasons for the increased risk for postoperative complications in patients with OUD are unknown, according to Dr. Soltesz, although a number of different mechanisms have been postulated. “Aside from the risk of withdrawal, patients with OUD have impaired wound healing and increased requirement for analgesics, both of which can contribute to any number of postoperative complications,” he said.
Patients with OUD also have a higher median length of stay (11 vs. 10 days) and a higher median total cost ($49,790 vs. $45,216).
However, two limitations of the study are the possibility that OUD was underreported and that the definitions of opioid dependence and persistent opioid use were inconsistent among hospitals.
Dr. Soltesz said future research should evaluate specific surgical factors and clinical outcomes to allow more thorough guidelines for the medical and surgical management of the OUD population, and to prevent adverse effects in the operative setting that may stem from prolonged opioid use.
Not Unexpected in This Population
Christopher Gharibo, MD, the medical director of pain medicine and an associate professor of anesthesiology, pain medicine and orthopedics at NYU Langone Health, in New York City, said the results of the study are not unexpected. “Patients with OUD tend to be individuals with poorly controlled anxiety, depression and general poor coping,” he said. “Some patients with OUD may even have opioid-induced hyperalgesia.”
Dr. Gharibo said the medical community must do a better job of screening patients for excessive preoperative pain, high-dose opioids, OUD, anxiety and other psychological problems. He added that there is a need to provide better preoperative patient education and expectation setting to this population. “Enhanced attention to this subset of patients in the perioperative period can reduce the incidence of major complications and improve cardiac surgery outcomes,” he said.
Dr. Gharibo added that a comprehensive screening program that addresses issues preoperatively also is applicable to other types of major surgery and would improve outcomes.