pharmacoepidemiology and drug safety 2014; 23: 1247–1257 Published online 14 April 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pds.3625
ORIGINAL REPORT
Chronic opioid use emerging after bariatric surgery† Marsha A. Raebel1,2*, Sophia R. Newcomer1, Elizabeth A. Bayliss1,3, Denise Boudreau4, Lynn DeBar5 and Thomas E. Elliott6‡, Ameena T. Ahmed7, Pamala A. Pawloski6, David Fisher7, Sengwee Toh8 and William Troy Donahoo3,9 1
Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora, CO, USA 3 University of Colorado School of Medicine, Aurora, CO, USA 4 Group Health Research Institute, Seattle, WA, USA 5 Kaiser Permanente Center for Health Research, Portland, OR, USA 6 Health Partners Institute for Education and Research, Minneapolis, MN, USA 7 The Permanente Medical Group, Oakland, CA, USA 8 Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA 9 Colorado Permanente Medical Group, Denver, CO, USA 2
ABSTRACT Purpose Little is known about opioid use after bariatric surgery among patients who did not use opioids chronically before surgery. Our purpose was to determine opioid use the year after bariatric surgery among patients who did not use opioids chronically pre-surgery and to identify pre-surgery characteristics associated with chronic opioid use after surgery. Methods This retrospective cohort study across nine US health systems included 10 643 patients aged 21 years or older who underwent bariatric surgery and who were not chronic opioid users pre-surgery. The main outcome was chronic opioid use the post-surgery year (excluding 30 post-operative days) defined as ≥10 dispensings over ≥90 days or ≥120 total days’ supply. Results Overall, 4.0% (n = 421) of patients became chronic opioid users the post-surgery year. Pre-surgery opioid total days’ supply was strongly associated with chronic use post-surgery (1–29 days adjusted odds ratio [OR] 1.89 [95%CI, 1.24–2.88]; 90–119 days OR, 14.29 [95%CI, 6.94–29.42] compared with no days). Other factors associated with increased likelihood of postsurgery chronic use included pre-surgery use of non-narcotic analgesics (OR, 2.22 [95%CI, 1.39–3.54]), antianxiety agents (OR, 1.67 [95%CI, 1.12–2.50]), and tobacco (OR, 1.44 [95%CI, 1.03–2.02]). Older age (OR, 0.84 [95%CI, 0.73–0.97] each decade) and a laparoscopic band procedure (OR, 0.42 [95%CI, 0.25–0.70] vs. laparoscopic bypass) were associated with decreased likelihood of chronic opioid use post-surgery. Conclusions Most patients who became chronic opioid users the year after bariatric surgery used opioids intermittently before surgery. Copyright © 2014 John Wiley & Sons, Ltd. key words—opioid; opiate; chronic opioid use; chronic pain; bariatric surgery; obesity; pharmacoepidemiology Received 9 January 2014; Revised 13 March 2014; Accepted 17 March 2014
INTRODUCTION Obesity and chronic opioid use for non-cancer pain are each important public health concerns. Obesity and chronic opioid use patterns have been separately
*Correspondence to: M. A. Raebel, Institute for Health Research, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237, USA. E-mail: [email protected] † Prior Publication: This material has not been previously published nor presented. ‡ At the time this work was done, T. E. Elliott worked at Essentia Institute of Rural Health, Duluth, MN, USA.
Copyright © 2014 John Wiley & Sons, Ltd.
studied,1–10 but we have limited knowledge about chronic opioid use specific to the obese population.11 We recently examined chronic opioid use among obese patients undergoing bariatric surgery and found 8% were chronic opioid users before surgery.11 Over three-fourths of these patients continued to use opioids chronically years after surgery, with daily opioid consumption increasing each post-surgery year despite dramatic weight loss.11 These findings highlighted the importance of identifying opioid use and optimizing chronic pain management in the bariatric surgery population, particularly given the lack of evidence
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supporting long-term effectiveness of opioids for chronic non-cancer pain.12,13 Patients with chronic opioid use before surgery are a small percentage of all bariatric surgery patients. We are not aware of any published studies that address opioid use after surgery in the majority of bariatric surgery patients who do not have chronic opioid use before surgery. The primary objective of this study was to evaluate the development of chronic opioid use the year after bariatric surgery among patients who did not use opioids, or who only had intermittent use of opioids, the year before bariatric surgery (i.e., they did not use opioids chronically before surgery), and to identify pre-surgery patient, temporal, and system characteristics associated with chronic opioid use emerging the year after surgery. Secondary objectives included exploring whether an association between any pre-surgery opioid use and post-surgery chronic opioid use was modified by selected pre-surgery factors including use of prescription nonnarcotic analgesics or adjunctive pain medications. METHODS Setting and population The patient cohort in this retrospective study was identified from the obesity data marts at nine health systems participating in the Scalable Partnering Network (SPAN) for comparative effectiveness research.11 Participating health systems included Group Health (Washington), Geisinger Health System (Pennsylvania), HealthPartners (Minnesota), Harvard Pilgrim (Massachusetts), and Kaiser Permanente regions in Colorado, Georgia, Hawaii, Northern California, and the Northwest (Oregon and Washington). Patients were included in this study if they underwent initial bariatric surgery between 1 January 2005 and 31 December 2009, were 21 years of age or older at the time of surgery, and were enrolled in the health system with a drug benefit during both the year before and the year after surgery. Patients were excluded if they used opioids chronically the year before surgery or if all documented body mass index measurements (BMI; weight in kilograms divided by height in meters squared) the year before surgery were
ORIGINAL REPORT
Chronic opioid use emerging after bariatric surgery† Marsha A. Raebel1,2*, Sophia R. Newcomer1, Elizabeth A. Bayliss1,3, Denise Boudreau4, Lynn DeBar5 and Thomas E. Elliott6‡, Ameena T. Ahmed7, Pamala A. Pawloski6, David Fisher7, Sengwee Toh8 and William Troy Donahoo3,9 1
Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora, CO, USA 3 University of Colorado School of Medicine, Aurora, CO, USA 4 Group Health Research Institute, Seattle, WA, USA 5 Kaiser Permanente Center for Health Research, Portland, OR, USA 6 Health Partners Institute for Education and Research, Minneapolis, MN, USA 7 The Permanente Medical Group, Oakland, CA, USA 8 Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA 9 Colorado Permanente Medical Group, Denver, CO, USA 2
ABSTRACT Purpose Little is known about opioid use after bariatric surgery among patients who did not use opioids chronically before surgery. Our purpose was to determine opioid use the year after bariatric surgery among patients who did not use opioids chronically pre-surgery and to identify pre-surgery characteristics associated with chronic opioid use after surgery. Methods This retrospective cohort study across nine US health systems included 10 643 patients aged 21 years or older who underwent bariatric surgery and who were not chronic opioid users pre-surgery. The main outcome was chronic opioid use the post-surgery year (excluding 30 post-operative days) defined as ≥10 dispensings over ≥90 days or ≥120 total days’ supply. Results Overall, 4.0% (n = 421) of patients became chronic opioid users the post-surgery year. Pre-surgery opioid total days’ supply was strongly associated with chronic use post-surgery (1–29 days adjusted odds ratio [OR] 1.89 [95%CI, 1.24–2.88]; 90–119 days OR, 14.29 [95%CI, 6.94–29.42] compared with no days). Other factors associated with increased likelihood of postsurgery chronic use included pre-surgery use of non-narcotic analgesics (OR, 2.22 [95%CI, 1.39–3.54]), antianxiety agents (OR, 1.67 [95%CI, 1.12–2.50]), and tobacco (OR, 1.44 [95%CI, 1.03–2.02]). Older age (OR, 0.84 [95%CI, 0.73–0.97] each decade) and a laparoscopic band procedure (OR, 0.42 [95%CI, 0.25–0.70] vs. laparoscopic bypass) were associated with decreased likelihood of chronic opioid use post-surgery. Conclusions Most patients who became chronic opioid users the year after bariatric surgery used opioids intermittently before surgery. Copyright © 2014 John Wiley & Sons, Ltd. key words—opioid; opiate; chronic opioid use; chronic pain; bariatric surgery; obesity; pharmacoepidemiology Received 9 January 2014; Revised 13 March 2014; Accepted 17 March 2014
INTRODUCTION Obesity and chronic opioid use for non-cancer pain are each important public health concerns. Obesity and chronic opioid use patterns have been separately
*Correspondence to: M. A. Raebel, Institute for Health Research, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237, USA. E-mail: [email protected] † Prior Publication: This material has not been previously published nor presented. ‡ At the time this work was done, T. E. Elliott worked at Essentia Institute of Rural Health, Duluth, MN, USA.
Copyright © 2014 John Wiley & Sons, Ltd.
studied,1–10 but we have limited knowledge about chronic opioid use specific to the obese population.11 We recently examined chronic opioid use among obese patients undergoing bariatric surgery and found 8% were chronic opioid users before surgery.11 Over three-fourths of these patients continued to use opioids chronically years after surgery, with daily opioid consumption increasing each post-surgery year despite dramatic weight loss.11 These findings highlighted the importance of identifying opioid use and optimizing chronic pain management in the bariatric surgery population, particularly given the lack of evidence
1248
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supporting long-term effectiveness of opioids for chronic non-cancer pain.12,13 Patients with chronic opioid use before surgery are a small percentage of all bariatric surgery patients. We are not aware of any published studies that address opioid use after surgery in the majority of bariatric surgery patients who do not have chronic opioid use before surgery. The primary objective of this study was to evaluate the development of chronic opioid use the year after bariatric surgery among patients who did not use opioids, or who only had intermittent use of opioids, the year before bariatric surgery (i.e., they did not use opioids chronically before surgery), and to identify pre-surgery patient, temporal, and system characteristics associated with chronic opioid use emerging the year after surgery. Secondary objectives included exploring whether an association between any pre-surgery opioid use and post-surgery chronic opioid use was modified by selected pre-surgery factors including use of prescription nonnarcotic analgesics or adjunctive pain medications. METHODS Setting and population The patient cohort in this retrospective study was identified from the obesity data marts at nine health systems participating in the Scalable Partnering Network (SPAN) for comparative effectiveness research.11 Participating health systems included Group Health (Washington), Geisinger Health System (Pennsylvania), HealthPartners (Minnesota), Harvard Pilgrim (Massachusetts), and Kaiser Permanente regions in Colorado, Georgia, Hawaii, Northern California, and the Northwest (Oregon and Washington). Patients were included in this study if they underwent initial bariatric surgery between 1 January 2005 and 31 December 2009, were 21 years of age or older at the time of surgery, and were enrolled in the health system with a drug benefit during both the year before and the year after surgery. Patients were excluded if they used opioids chronically the year before surgery or if all documented body mass index measurements (BMI; weight in kilograms divided by height in meters squared) the year before surgery were
