Health Care Spending and New Persistent Opioid Use After Surgery.

OBJECTIVE: We sought to describe the differences in health care spending and utilization among patients who develop persistent postoperative opioid use. SUMMARY OF BACKGROUND DATA: Although persistent opioid use following surgery has garnered concern, its impact on health care costs and utilization remains unknown. METHODS: We examined insurance claims among 133,439 opioid-naive adults undergoing surgery. Outcomes included 6-month postoperative health care spending; proportion of spending attributable to admission, readmission, ambulatory or emergency care; monthly spending 6 months before and following surgery. We defined persistent opioid use as continued opioid fills beyond 3 months postoperatively. We used linear regression to estimate outcomes adjusting for clinical covariates. RESULTS: In this cohort, 8103 patients developed persistent opioid use. For patients who underwent inpatient procedures, new persistent opioid use was associated with health care spending (+$2700 per patient, P < 0.001) compared with patients who did not develop new persistent use. For patients who underwent outpatient procedures, new persistent opioid use was similarly correlated with higher health care spending (+$1500 per patient, P < 0.001) compared with patients who did not develop new persistent use. Patients without persistent opioid use returned to baseline health care spending within 6 months, regardless of other complications. However, patients with persistent opioid use had sustained increases in spending by approximately $200 per month. CONCLUSION: Unlike other postoperative complications, persistent opioid use is associated with sustained increases in spending due to greater readmissions and ambulatory care visits. Early identification of patients vulnerable to persistent use may enhance the value of surgical care.

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

Purpose The current epidemic of prescription opioid misuse has increased scrutiny of postoperative opioid prescribing. Some 6% to 8% of opioid-naïve patients undergoing noncancer procedures develop new persistent opioid use; however, it is unknown if a similar risk applies to patients with cancer. We sought to define the risk of new persistent opioid use after curative-intent surgery, identify risk factors, and describe changes in daily opioid dose over time after surgery. Methods Using a national data set of insurance claims, we identified patients with cancer undergoing curative-intent surgery from 2010 to 2014. We included melanoma, breast, colorectal, lung, esophageal, and hepato-pancreato-biliary/gastric cancer. Primary outcomes were new persistent opioid use (opioid-naïve patients who continued filling opioid prescriptions 90 to 180 days after surgery) and daily opioid dose (evaluated monthly during the year after surgery). Logistic regression was used to identify risk factors for new persistent opioid use. Results A total of 68,463 eligible patients underwent curative-intent surgery and filled opioid prescriptions. Among opioid-naïve patients, the risk of new persistent opioid use was 10.4% (95% CI, 10.1% to 10.7%). One year after surgery, these patients continued filling prescriptions with daily doses similar to chronic opioid users ( P = .05), equivalent to six tablets per day of 5-mg hydrocodone. Those receiving adjuvant chemotherapy had modestly higher doses ( P = .002), but patients with no chemotherapy still had doses equivalent to five tablets per day of 5-mg hydrocodone. Across different procedures, the covariate-adjusted risk of new persistent opioid use in patients receiving adjuvant chemotherapy was 15% to 21%, compared with 7% to 11% for those with no chemotherapy. Conclusion New persistent opioid use is a common iatrogenic complication in patients with cancer undergoing curative-intent surgery. This problem requires changes to prescribing guidelines and patient counseling during the surveillance and survivorship phases of care.

Severe hypotension after interscalene block for outpatient shoulder surgery: a case report.

The case of a 43 year-old woman who underwent successful right interscalene brachial plexus block for arthroscopic shoulder surgery is presented. During the surgery, she subsequently exhibited signs of neuraxial spread of local anesthetic. Bilateral motor block was noted postoperatively. Spontaneous ventilation was maintained throughout the case, and she was successfully discharged home several hours after the procedure with no residual symptoms.