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Perez JJ, Strunk JD, Preciado OM, DeFaccio RJ, Chang LC, Mallipeddi MK, Deal SB, Oryhan CL. Effect of an opioid-free anesthetic on postoperative opioid consumption after laparoscopic bariatric surgery: a prospective, single-blinded, randomized controlled trial. Reg Anesth Pain Med 2024:rapm-2024-105632. [PMID: 38839427 DOI: 10.1136/rapm-2024-105632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Opioid administration has the benefit of providing perioperative analgesia but is also associated with adverse effects. Opioid-free anesthesia (OFA) may reduce postoperative opioid consumption and adverse effects after laparoscopic bariatric surgery. In this randomized controlled study, we hypothesized that an opioid-free anesthetic using lidocaine, ketamine, and dexmedetomidine would result in a clinically significant reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique. METHODS Subjects presenting for laparoscopic or robotic bariatric surgery were randomized in a 1:1 ratio to receive either standard opioid-inclusive anesthesia (group A: control) or OFA (group B: OFA). The primary outcome was opioid consumption in the first 24 hours postoperatively in oral morphine equivalents (OMEs). Secondary outcomes included postoperative pain scores, patient-reported incidence of opioid-related adverse effects, hospital length of stay, patient satisfaction, and ongoing opioid use at 1 and 3 months after hospital discharge. RESULTS 181 subjects, 86 from the control group and 95 from the OFA group, completed the study per protocol. Analysis of the primary outcome showed no significant difference in total opioid consumption at 24 hours between the two treatment groups (control: 52 OMEs vs OFA: 55 OMEs, p=0.49). No secondary outcomes showed statistically significant differences between groups. CONCLUSIONS This study demonstrates that an OFA protocol using dexmedetomidine, ketamine, and lidocaine for laparoscopic or robotic bariatric surgery was not associated with a reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique using fentanyl.
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Affiliation(s)
- Josiah Joco Perez
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Joseph D Strunk
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Octavio M Preciado
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | | | - Lily C Chang
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Mohan K Mallipeddi
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Shanley B Deal
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Christine L Oryhan
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
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Jirapinyo P, Hadefi A, Thompson CC, Patai ÁV, Pannala R, Goelder SK, Kushnir V, Barthet M, Apovian CM, Boskoski I, Chapman CG, Davidson P, Donatelli G, Kumbhari V, Hayee B, Esker J, Hucl T, Pryor AD, Maselli R, Schulman AR, Pattou F, Zelber-Sagi S, Bain PA, Durieux V, Triantafyllou K, Thosani N, Huberty V, Sullivan S. American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity. Gastrointest Endosc 2024; 99:867-885.e64. [PMID: 38639680 DOI: 10.1016/j.gie.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 04/20/2024]
Abstract
This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Alia Hadefi
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Árpád V Patai
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stefan K Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Vladimir Kushnir
- Department of Medicine-Division of Gastroenterology, Washington University, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marc Barthet
- Department of Hepatogastroenterology, Faculty of Medicine, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Caroline M Apovian
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Christopher G Chapman
- Center for Interventional and Therapeutic Endoscopy, Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois USA
| | - Paul Davidson
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France and Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bu Hayee
- Division of Gastroenterology, Kings College London, London, United Kingdom
| | - Janelle Esker
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Aurora D Pryor
- Department of Surgery, Long Island Jewish Medical Center, Queens, New York, USA
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy and Humanitas Clinical and Research Center IRCCS, Endoscopy Unit, Rozzano, Italy
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Francois Pattou
- Department of Endocrine and Metabolic Surgery, CHU Lille, University of Lille, Inserm, Institut Pasteur Lille, Lille, France
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel and Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles, Brussels, Belgium
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, Division of Gastroenterology Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Vincent Huberty
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Shelby Sullivan
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Jirapinyo P, Hadefi A, Thompson CC, Patai ÁV, Pannala R, Goelder SK, Kushnir V, Barthet M, Apovian CM, Boskoski I, Chapman CG, Davidson P, Donatelli G, Kumbhari V, Hayee B, Esker J, Hucl T, Pryor AD, Maselli R, Schulman AR, Pattou F, Zelber-Sagi S, Bain PA, Durieux V, Triantafyllou K, Thosani N, Huberty V, Sullivan S. American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity. Endoscopy 2024; 56:437-456. [PMID: 38641332 DOI: 10.1055/a-2292-2494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alia Hadefi
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Árpád V Patai
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stefan K Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Vladimir Kushnir
- Department of Medicine-Division of Gastroenterology, Washington University, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marc Barthet
- Department of Hepatogastroenterology, Faculty of Medicine, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Caroline M Apovian
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Christopher G Chapman
- Center for Interventional and Therapeutic Endoscopy, Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois USA
| | - Paul Davidson
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France and Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bu Hayee
- Division of Gastroenterology, Kings College London, London, United Kingdom
| | - Janelle Esker
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Aurora D Pryor
- Department of Surgery, Long Island Jewish Medical Center, Queens, New York, USA
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy and Humanitas Clinical and Research Center IRCCS, Endoscopy Unit, Rozzano, Italy
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Francois Pattou
- Department of Endocrine and Metabolic Surgery, CHU Lille, University of Lille, Inserm, Institut Pasteur Lille, Lille, France
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel and Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles, Brussels, Belgium
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, Division of Gastroenterology Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Vincent Huberty
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Shelby Sullivan
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Martinelli S, Petrucciani N, Regazzi L, Gualano MR. Bariatric Surgery and New-Onset Substance Use Disorders: A Systematic review and Meta-analysis. Obes Surg 2024; 34:1366-1375. [PMID: 38430321 PMCID: PMC11026269 DOI: 10.1007/s11695-024-07130-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
Increasing evidence suggests that bariatric surgery (BS) patients are at risk for substance abuse disorders (SUD). The purpose of this systematic review and meta-analysis was to determine the relationship between BS and the development of new-onset substance abuse disorder (SUDNO) in bariatric patients. On October 31, 2023, we reviewed the scientific literature following PRISMA guidelines. A total of 3242 studies were analyzed, 7 met the inclusion criteria. The pooled incidence of SUDNO was 4.28%. Patients' characteristics associated with SUDNO included preoperative mental disorders, high pre-BS BMI, and public health insurance. Surgical factors associated with new SUDNOs included severe complications in the peri- or postoperative period. The occurrence of SUDNOs is a non-negligeable complication after BS. Predisposing factors may be identified and preventive actions undertaken.
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Affiliation(s)
- Silvia Martinelli
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Niccolò Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, Division of General and Hepatobiliary Surgery, St. Andrea Hospital, Sapienza University of Rome, Via Di Grottarossa 1035-9, 00189, Rome, Italy.
| | - Luca Regazzi
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Rosaria Gualano
- Unicamillus - Saint Camillus International University of Health and Medical Sciences, Rome, Italy
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5
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Moy BM, Volk S, Richards B, Guduguntla BA, Schulman AR. Use of Postoperative Opioid Therapy Following Endoscopic Sleeve Gastroplasty. Am J Gastroenterol 2024:00000434-990000000-00977. [PMID: 38235688 DOI: 10.14309/ajg.0000000000002665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/03/2024] [Indexed: 01/19/2024]
Abstract
INTRODUCTION There are no established guidelines on periprocedural and postprocedural pain management after endoscopic sleeve gastroplasty (ESG). This study aimed to determine the need for perioperative and postoperative opioid therapy in patients undergoing ESG. METHODS This retrospective study comprised consecutive patients undergoing ESG. The primary outcome was the percentage of patients requiring postoperative outpatient opioid therapy. Secondary outcomes included frequency and dosage of perioperative pain medications and postoperative pain scores. RESULTS Of the 67 patients included, 39 (58.2%) required opioids in the perioperative setting. The mean ± SD opioid dose was 12.3 ± 8.4 morphine milligram equivalents. Postoperatively, 17.9% of patients required home opioid prescriptions. More than a third of patients reported no pain. DISCUSSION In patients undergoing ESG, postoperative opioid therapy should be individualized to attenuate opioid overprescription and the risk of opioid overuse.
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Affiliation(s)
- Benjamin M Moy
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sarah Volk
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Wallén S, Szabo E, Palmetun-Ekbäck M, Näslund I, Ottosson J, Näslund E, Stenberg E. Impact of socioeconomic status on new chronic opioid use after gastric bypass surgery. Surg Obes Relat Dis 2023; 19:1375-1381. [PMID: 37532668 DOI: 10.1016/j.soard.2023.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/02/2023] [Accepted: 06/17/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Socioeconomic status may influence weight loss, postoperative complications, and health-related quality of life after bariatric surgery. Chronic use of opioid analgesics is a known risk after bariatric surgery, but whether socioeconomic factors are associated with new chronic use of opioid analgesics has not been investigated in depth. OBJECTIVES The aim of this study was to identify socioeconomic factors associated with the development of new chronic use of opioid analgesics after gastric bypass surgery. SETTING All hospitals performing bariatric surgery in Sweden. METHODS This was a retrospective cohort study with prospectively collected data including all primary gastric bypass procedures in Sweden between 2007 and 2015. Data were collected from the Scandinavian Obesity Surgery Registry, the Swedish Prescribed Drug Register, and Statistics Sweden. The primary outcome was new chronic opioid use. RESULTS Of the 44,671 participants, 1438 patients became new chronic opioid users. Longer education (secondary education; odds ratio [OR] = .71; 95% CI, .62-.81) or higher education (OR = .45; 95% CI, .38-.53), higher disposable income (20th-50th percentile: OR = .75; 95% CI, .66-.85; 50th-80th percentile: OR = .50; 95% CI, .43-.58; and the highest 80th percentile: OR = .40; 95% CI, .32-.51) were significantly associated with lower risk for new chronic opioid use. Being a second-generation immigrant (OR = 1.54; 95% CI, 1.24-1.90), being on a disability pension or early retirement (OR = 3.04; 95% CI, 2.67-3.45), receiving social benefits (OR = 1.88; 95% CI, 1.59-2.22), being unemployed for <100 days (OR = 1.25; 95% CI, 1.08-1.45), being unemployed for >100 days (OR = 1.41; 95% CI, 1.16-1.71), and being divorced or a widow or widower (OR = 1.35; 95% CI, 1.17-1.55) were significantly associated with a higher risk for chronic opioid use. CONCLUSION Given that long-term opioid use has detrimental effects after bariatric surgery, it is important that information and follow-up are optimized for patients with shorter education, lower income, and disability pension or early retirement because they are at an increased risk of new chronic opioid analgesics use.
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Affiliation(s)
- Stefan Wallén
- Pharmacology and Therapeutic Department, School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - Eva Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Maria Palmetun-Ekbäck
- Pharmacology and Therapeutic Department, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ingmar Näslund
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Erik Näslund
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Janes LA, Hammond JW, Bonham AJ, Carlin AM, Ghaferi AA, Varban OA, Ehlers AP, Finks JF. The effect of marijuana use on short-term outcomes with bariatric surgery. Surg Obes Relat Dis 2023; 19:964-970. [PMID: 37142472 DOI: 10.1016/j.soard.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 02/16/2023] [Accepted: 02/24/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Despite increasing marijuana use nationwide, there are limited data on implications of marijuana use on bariatric surgery outcomes. OBJECTIVE We investigated associations between marijuana use and bariatric surgery outcomes. SETTING Multicenter statewide study utilizing data from the Michigan Bariatric Surgery Collaborative, a payor-funded consortium including over 40 hospitals and 80 surgeons performing bariatric surgery statewide. METHODS We analyzed data from the Michigan Bariatric Surgery Collaborative clinical registry on patients who underwent a laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between June 2019 and June 2020. Patients were surveyed at baseline and annually on medication use, depression symptoms, and substance use. Regression analysis was performed to compare 30-day and 1-year outcomes between marijuana users and nonusers. RESULTS Of 6879 patients, 574 reported baseline marijuana use and 139 reported use at baseline and 1 year. Marijuana users were more likely to be current smokers (14% versus 8%, P < .0001), screen positive for alcohol use disorder (20.0% versus 8.4%, P < .0001), and score higher on the Patient Health Questionnaire-8 (6.1 versus 3.0, P < .0001). There were no statistically significant differences in 30-day outcomes or co-morbidity remission at 1 year. Marijuana users had higher adjusted total mean weight loss (47.6 versus 38.1 kg, P < .0001) and body mass index reduction (17 versus 14 kg/m2, P < .0001). CONCLUSIONS Marijuana use is not associated with worse 30-day outcomes or 1-year weight loss outcomes and should not be a barrier to bariatric surgery. However, marijuana use is associated with higher rates of smoking, substance use, and depression. These patients may benefit from additional mental health and substance abuse counseling.
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Affiliation(s)
| | - John W Hammond
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Aaron J Bonham
- University of Michigan, Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Arthur M Carlin
- Henry Ford Health, Michigan Bariatric Surgery Collaborative, Detroit, Michigan
| | - Amir A Ghaferi
- University of Michigan, Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Oliver A Varban
- University of Michigan, Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Anne P Ehlers
- University of Michigan, Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Jonathan F Finks
- University of Michigan, Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan.
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8
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Dennis A, Deng C, Yang P, Bonham AJ, Carlin AM, Varban OA. Evaluating the impact of metabolic surgery on patients with prior opioid use. Surg Obes Relat Dis 2023; 19:889-896. [PMID: 36872158 DOI: 10.1016/j.soard.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/14/2023] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Metabolic surgery is the most effective treatment for obesity and may improve obesity-related pain syndromes. However, the effect of surgery on the persistent use of opioids in patients with a history of prior opioid use remains unclear. OBJECTIVE To determine the effect of metabolic surgery on opioid use behaviors in patients with prior opioid use. SETTING A consortium of public and private hospitals in Michigan. METHODS Using a statewide metabolic-specific data registry, we identified 16,820 patients who self-reported opioid use before undergoing metabolic surgery between 2006 and 2020 and analyzed the 8506 (50.6%) patients who responded to 1-year follow-up. We compared patient characteristics, risk-adjusted 30-day postoperative outcomes, and weight loss between patients who self-reported discontinuing opioid use 1 year after surgery and those who did not. RESULTS Among patients who self-reported using opioids before metabolic surgery, 3864 (45.4%) discontinued use 1 year after surgery. Predictors of persistent opioid use included an annual income of <$10,000 (odds ratio [OR] = 1.24; 95% confidence interval [CI], 1.06-1.44; P = .006), Medicare insurance (OR = 1.48; 95% CI, 1.32-1.66; P < .0001), and preoperative tobacco use (OR = 1.36; 95% CI, 1.16-1.59; P = .0001). Patients with persistent use were more likely to have a surgical complication (9.6% versus 7.5%, P = .0328) and less percent excess weight loss (61.6% versus 64.4%, P < .0001) than patients who discontinued opioids after surgery. There were no differences in the morphine milligram equivalents prescribed within the first 30 days following surgery between groups (122.3 versus 126.5, P = .3181). CONCLUSIONS Nearly half of patients who reported taking opioids before metabolic surgery discontinued use at 1 year. Targeted interventions aimed at high-risk patients may increase the number of patients who discontinue opioid use after metabolic surgery.
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Affiliation(s)
| | - Callie Deng
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Phillip Yang
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Aaron J Bonham
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | | | - Oliver A Varban
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
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9
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Lin N, Dabas E, Quan ML, Cheung WY, Cuthbert C, Feng Y, Kong S, Sauro KM, Brenner DR, Yang L, Lu M, Xu Y. Outcomes and Healthcare Utilization Among New Persistent Opioid Users and Nonopioid Users After Curative-intent Surgery for Cancer. Ann Surg 2023; 277:e752-e758. [PMID: 34334636 DOI: 10.1097/sla.0000000000005109] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare the health outcomes and resource use of cancer patients who were new persistent opioid users with those who were not, after undergoing curative intent surgery for cancer. BACKGROUND Little is known about long-term health outcomes (overdose, mortality) and resource utilization of new persistent opioid users among cancer patients undergoing curative-intent surgery. METHODS This retrospective cohort study included all adults with a diagnosis of solid cancers who underwent curative-intent surgery during the study period (2011-2015) in Alberta, Canada and were opioid-naïve before surgery, with a follow-up period until December 31, 2019. The key exposure, "new persistent opioid user," was defined as a patient who was opioid-naive before surgery and subsequently filled at least 1 opioid prescription between 60 and 180 days after surgery. The primary outcome was opioid overdose that occurred within 3 years of surgery. All-cause death, noncancer caused death, and department visit (yes vs. no), and hospitalization (yes vs. no) in the follow-up periods were also included as outcomes. RESULTS In total, 19,219 patients underwent curative intent surgery with a median follow-up of 47 months, of whom 1530 (8.0%) were identified as postoperative new persistent opioid users. In total, 101 (0.5%) patients experienced opioid overdose within 3 years of surgery. Compared with nonopioid users, new persistent opioid users experienced a higher rate of opioid overdose (OR = 2.37, 95% CI: 1.44-3.9) within 3 years of surgery. New persistent opioid use was also associated with a greater likelihood of being hospitalized (OR = 2.03, 95% CI: 1.76-2.33) and visiting an emergency room (OR = 1.83, 95% CI: 1.62-2.06) in the first year after surgery, and a higher overall (HR = 1.28, 95% CI: 1.1-1.49) and noncancer caused mortality (HR = 1.33, 95% CI: 1.12-1.58), when compared with nonopioid users. CONCLUSION Postoperative new persistent opioid use among cancer patients undergoing curative-intent surgery is associated with subsequent opioid overdose, worse survival, and more health resource utilization.
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Affiliation(s)
- Na Lin
- The Center for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eashita Dabas
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - May Lynn Quan
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Winson Y Cheung
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Colleen Cuthbert
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Yuanchao Feng
- The Center for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shiying Kong
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Khara M Sauro
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darren R Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Lin Yang
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Mingshan Lu
- Department of Economics, Faculty of Arts, University of Calgary, Calgary, Alberta, Canada
| | - Yuan Xu
- The Center for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Jatana S, Verhoeff K, Mocanu V, Jogiat U, Birch DW, Karmali S, Switzer NJ. Substance abuse screening prior to bariatric surgery: an MBSAQIP cohort study evaluating frequency and factors associated with screening. Surg Endosc 2023:10.1007/s00464-023-10026-9. [PMID: 36991265 DOI: 10.1007/s00464-023-10026-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/12/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION Patients undergoing bariatric surgery experience substantial risk of pre- and postoperative substance use. Identifying patients at risk for substance use using validated screening tools remains crucial to risk mitigation and operative planning. We aimed to evaluate proportion of bariatric surgery patients undergoing specific substance abuse screening, factors associated with screening and the relationship between screening and postoperative complications. METHODS The 2021 MBSAQIP database was analyzed. Bivariate analysis was performed to compare factors between groups who were screened for substance abuse versus non-screened, and to compare frequency of outcomes. Multivariate logistic regression analysis was performed to assess the independent effect of substance screening on serious complications and mortality, and to assess factors associated with substance abuse screening. RESULTS A total of 210, 804 patients were included, with 133,313 (63.2%) undergoing screening and 77,491 (36.8%) who did not. Those who underwent screening were more likely to be white, non-smoker, and have more comorbidities. The frequency of complications was not significant (e.g., reintervention, reoperation, leak) or similar (readmission rates 3.3% vs. 3.5%) between screened and not screened groups. On multivariate analysis, lower substance abuse screening was not associated with 30-day death or 30-day serious complication. Factors that significantly affected likelihood of being screened for substance abuse included being black (aOR 0.87, p < 0.001) or other race (aOR 0.82, p < 0.001) compared to white, being a smoker (aOR 0.93, p < 0.001), having a conversion or revision procedure (aOR 0.78, p < 0.001; aOR 0.64, p < 0.001, respectively), having more comorbidities and undergoing Roux-en-y gastric bypass (aOR 1.13, p < 0.001). CONCLUSION There remains significant inequities in substance abuse screening in bariatric surgery patients regarding demographic, clinical, and operative factors. These factors include race, smoking status, presence of preoperative comorbidities, and procedure type. Further awareness and initiatives highlighting the importance of identifying at risk patients is critical for ongoing outcome improvement.
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Opioid prescribing practices following bariatric surgery: a systematic review and pooled proportion meta-analysis. Surg Endosc 2023; 37:62-74. [PMID: 35927352 DOI: 10.1007/s00464-022-09481-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/13/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION A paucity of literature exists regarding current opioid prescribing and use following bariatric surgery. We aimed to characterize opioid prescribing practices and use following bariatric surgery to inform future studies and optimized prescribing practices. METHODS AND PROCEDURE We performed a systematic review of Ovid MEDLINE, Ovid Embase, Scopus, Web of Science Core Collection, and Cochrane Library (via WILEY) on August 20, 2021. Two reviewers reviewed and extracted data independently. Studies evaluating adult patients undergoing bariatric surgery that reported opioid prescriptions at discharge were included. Abstracts, non-English studies, and those with n < 5 were excluded. Primary outcomes assessed the amount of morphine milligram equivalents (MMEs) prescribed at discharge. Secondary outcomes evaluated opioids used following discharge, proportion of patients with unused opioid, and if unused opioids were properly discarded. RESULTS We evaluated 2113 studies, with 18 undergoing full-text review, and 5 meeting inclusion criteria. Overall, 847 patients were included, with 450 (53%) undergoing sleeve gastrectomy and 393 (46%) receiving Roux-en-Y gastric bypass. Most patients were female (n = 484/589, 82.2%), and the average age and BMI were 44.6 (± 11.8) years and 48.1 kg/m2 (± 8.4 kg/m2), respectively. On average, 348.4 MMEs were prescribed to patients undergoing bariatric surgery. Patients used only 84.7 MMEs, with 87.0% (95% CI 66.0-99.0%) having unused opioid, and 41/120 (34.2%) retaining these excess opioids. CONCLUSION Nearly 90% of all bariatric patients evaluated in our systematic review are prescribed excessive opioids at discharge. Further work characterizing current opioid prescribing practices and use may help guide development of standardized post-bariatric surgery prescription guidelines.
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Torensma B, Hany M, Bakker MJS, van Velzen M, in ’t Veld BA, Dahan A, Swank DJ. Cross-sectional E-survey on the Incidence of Pre- and Postoperative Chronic Pain in Bariatric Surgery. Obes Surg 2023; 33:204-210. [PMID: 36344727 PMCID: PMC9834162 DOI: 10.1007/s11695-022-06354-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND To assess the prevalence, incidence, location, and behavior of chronic pre- and postoperative pain in bariatric surgery, and the use of analgesics. METHODS A cross-sectional e-survey was conducted on 3928 post-bariatric patients and four-time points for pain assessment were evaluated: preoperative, on the ward, day 1 at home postoperatively, and present time (at the time of the e-survey). A numerical rating scale (NRS) was used to assess the level of pain (0 to 10). The general incidence of chronic pain was calculated, as also, subgroups were defined as group A (pre and postoperative chronic pain), B (preoperative pain, and no longer postoperative), and C (preoperative painless, postoperative chronic pain). Besides the pain intensity, location of pain, and the use of analgesics were investigated. RESULTS A total of 3279 patients (83.9%) responded to the survey. Preoperative and postoperative chronic pain was found in 343 (10.5%) and 264 (8.1%) patients, respectively. In group A, chronic pain was present in 4.8% of the patients; in group B, it was present in 5.7%; and in group C in 3.3% of the patients. Furthermore, in 4.5% of patients pain was located in the abdomen, which was higher as compared to before surgery (+ 2.3%, p < 0.001). The ORs for present postoperative chronic pain were OR 1.45, 1.7, and 1.71 (p = 0.002, 0.003, 0.003) compared to respectively preoperative chronic pain, pain at the ward, and pain at day 1 after surgery. Among all participants, 4.6% consumed chronic analgesics. Of these, paracetamol was used most frequently (3.8%), followed by tramadol (1.3%) and oxycodone (0.5%). CONCLUSIONS In this e-survey, chronic postoperative abdominal pain was prominent in patients after bariatric surgery. Of patients, 3.3% that were without preoperative chronic pain developed chronic pain after surgery. Opioid consumption in the queried population was relatively low.
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Affiliation(s)
- Bart Torensma
- Department of Anaesthesiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333 ZA Leiden, the Netherlands ,Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Mohammed Hany
- Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Marije J. S. Bakker
- Department of Anaesthesiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Monique van Velzen
- Department of Anaesthesiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | | | - Albert Dahan
- Department of Anaesthesiology, Leiden University Medical Center (LUMC), Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Nasser K, Verhoeff K, Mocanu V, Kung JY, Purich K, Switzer NJ, Birch DW, Karmali S. New persistent opioid use after bariatric surgery: a systematic review and pooled proportion meta-analysis. Surg Endosc 2023; 37:703-714. [PMID: 35534738 DOI: 10.1007/s00464-022-09291-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/18/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Increasing evidence suggests surgical patients are at risk for developing new, persistent opioid use (NPOU) following surgery. This risk may be heightened for patients undergoing bariatric surgery. Few studies have evaluated this important long-term outcome and little is known about the rate of NPOU, or factors associated with NPOU for bariatric surgery patients. METHODS AND PROCEDURE We conducted a systematic review of MEDLINE, Embase, Scopus, Web of Science, and Cochrane databases in August 2021. Studies were reviewed and data extracted independently by two reviewers following MOOSE guidelines. Studies evaluating bariatric surgery patients reporting NPOU, defined as new opioid use > 90 days after surgery, were included. Abstracts, non-English, animal, n < 5, and pediatric studies were excluded. Primary outcome was NPOU prevalence, and secondary outcomes were patient and surgical factors associated with NPOU. Factors associated with NPOU are reported from findings of individual studies; meta-analysis could not be completed due to heterogeneity of reporting. RESULTS We retrieved a total of 2113 studies with 8 meeting inclusion criteria. In studies reporting NPOU rates (n = 4 studies), pooled prevalence was 6.0% (95% CI 4.0-7.0%). Patient characteristics reported by studies to be associated with NPOU included prior substance use (tobacco, alcohol, other prescription analgesics), preoperative mental health disorder (anxiety, mood disorders, eating disorders), and public health insurance. Surgical factors associated with NPOU included severe post-operative complications and in-hospital opioid use (peri- or post operatively). CONCLUSIONS NPOU is an uncommon but important complication following bariatric surgery, with patient factors including prior substance abuse, mental health disorders, and use of public health insurance placing patients at increased risk, and surgical factors being complications and peri-operative opioid use. Studies evaluating techniques to reduce NPOU in these high-risk populations are needed.
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Affiliation(s)
- Khadija Nasser
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, AB, Canada. .,Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom, 2G2 Walter C. Mackenzie Health Sciences Centre, 8440, 112 St NW, Edmonton, AB, T6G 2B7, Canada.
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Janice Y Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Kieran Purich
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Daniel W Birch
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB, Canada
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Vitous CA, Carlin AM, Waljee J, Stricklen A, Ross R, Ghaferi A, Ehlers AP. Factors that influence discharge opioid prescribing among bariatric surgeons across Michigan. Am J Surg 2023; 225:184-190. [PMID: 35933183 DOI: 10.1016/j.amjsurg.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Opioid prescribing following bariatric surgery has been a focus due to its association with new persistent opioid use (NPOU) and worse outcomes. Guidelines have led to a reduction in opioids prescribed, but there remains variation in prescribing practices. METHODS We conducted interviews with 20 bariatric surgeons across Michigan. Transcripts were analyzed using descriptive content analysis. RESULTS At the patient level, surgeons described the role of surgical history and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, reputation, and workload. At the institution level, surgeons discussed colleagues, resources, and administration. At a collaborative level, surgeons described the role of evidence and performance measures. There was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery. CONCLUSION Despite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices. Understanding determinants that impact stakeholder alignment is critical to increasing adherence to guideline-concordant care.
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Affiliation(s)
- C Ann Vitous
- Michigan Bariatric Surgical Collaborative, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States.
| | - Arthur M Carlin
- Michigan Bariatric Surgical Collaborative, United States; Henry Ford Health System, Detroit, United States
| | - Jennifer Waljee
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States; Department of Surgery, University of Michigan, Ann Arbor, United States
| | | | - Rachel Ross
- Michigan Bariatric Surgical Collaborative, United States
| | - Amir Ghaferi
- Michigan Bariatric Surgical Collaborative, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States; Department of Surgery, University of Michigan, Ann Arbor, United States
| | - Anne P Ehlers
- Michigan Bariatric Surgical Collaborative, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States; Department of Surgery, University of Michigan, Ann Arbor, United States
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Yang P, Bonham AJ, Carlin AM, Finks JF, Ghaferi AA, Varban OA. Patient characteristics and outcomes among bariatric surgery patients with high narcotic overdose scores. Surg Endosc 2022; 36:9313-9320. [PMID: 35411461 DOI: 10.1007/s00464-022-09205-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/21/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Obesity-related chronic pain can increase the risk of narcotic abuse in bariatric surgery patients. However, assessment of overdose risk has not been evaluated to date. METHODS A NARxCHECK® overdose score ("Narx score") was obtained preoperatively on all patients undergoing bariatric surgery (n = 306) between 2018 and 2020 at a single-center academic bariatric surgery program. The 3-digit score ranges from 000 to 999 and is based on patient risk factors found within the Prescription Drug Monitoring Program. A Narx score ≥ 200 indicates tenfold increased risk of narcotic overdose. Patient characteristics, comorbidities, and emergency room (ER) visits were compared between patients in the upper (≥ 200) and lower (000) terciles of Narx scores. Morphine milligram equivalent (MME) prescribed at discharge and refills was also evaluated. RESULTS Patients in the upper tercile represented 32% (n = 99) of the study population, and compared to the lower tercile (n = 101, 33%), were more likely to have depression (63.6% vs 38.6%, p = 0.0004), anxiety (47.5% vs 30.7%, p = 0.0150), and bipolar disorder (6.1% vs 0.0%, p = 0.0120). Median MME prescribed at discharge was the same between both groups (75); however, high-risk patients were more likely to be prescribed more than 10 tablets of a secondary opioid (83.3% vs 0.0%, p = 0.0111), which was prescribed by another provider in 67% of cases. ER visits among patients who did not have a complication or require a readmission was also higher among high-risk patients (7.8% vs 0.0%, p = 0.0043). There were no deaths or incidents of mental health-related ER visits in either group. CONCLUSION Patients with a Narx score ≥ 200 were more likely to have mental health disorders and have potentially avoidable ER visits in the setting of standardized opioid prescribing practices. Narx scores can help reduce ER visits by identifying at-risk patients who may benefit from additional clinic or telehealth follow-up.
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Affiliation(s)
- Phillip Yang
- 2926 Taubman Center, University of Michigan Medical School, 1500 E Medical Center Drive, SPC 5343, Ann Arbor, MI, 48109-5343, USA.
| | - Aaron J Bonham
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | | | - Amir A Ghaferi
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Oliver A Varban
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
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Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery. Surg Endosc 2022; 37:3103-3112. [PMID: 35927346 DOI: 10.1007/s00464-022-09482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients. METHODS A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME). RESULTS A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1 years, mean BMI 49.2 kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation. CONCLUSION Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.
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Tan MM, Jin X, Taylor C, Low AK, Le Page P, Martin D, Li A, Joseph D, Kormas N. Long-Term Trajectories in Weight and Health Outcomes Following Multidisciplinary Publicly Funded Bariatric Surgery in Patients with Clinically Severe Obesity (≥ 3 Associated Comorbidities): A Nine-Year Prospective Cohort Study in Australia. J Clin Med 2022; 11:4466. [PMID: 35956083 PMCID: PMC9369852 DOI: 10.3390/jcm11154466] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/18/2022] [Accepted: 07/23/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Real-world data on long-term (> 5 years) weight loss and obesity-related complications after newer bariatric surgical procedures are currently limited. The aim of this longitudinal study was to examine the effectiveness and sustainability of bariatric surgery in a cohort with clinically severe obesity in a multidisciplinary publicly funded service in two teaching hospitals in New South Wales, Australia. Methods: Patients were adults with complex clinically severe obesity with a BMI ≥ 35 kg/m2 and at least three significant obesity-related comorbidities, who underwent bariatric surgeries between 2009 and 2017. Detailed obesity-related health outcomes were reported from annual clinical data and assessments for up to 9 years of follow-up. Data were also linked with the national joint replacement registry. Results: A total of 65 eligible patients were included (mean, 7; range, 3−12 significant obesity-related comorbidities); 53.8% female; age 54.2 ± 11.2 years, with baseline BMI 52.2 ± 12.5 kg/m2 and weight 149.2 ± 45.5 kg. Most underwent laparoscopic sleeve gastrectomy (80.0%), followed by laparoscopic adjustable gastric banding (10.8%) and one anastomosis gastric bypass (9.2%). Substantial weight loss was maintained over 9 years of follow-up (p < 0.001 versus baseline). Significant total weight loss (%TWL ± SE) was observed (13.2 ± 2.3%) following an initial 1-year preoperative intensive lifestyle intervention, and ranged from 26.5 ± 2.3% to 33.0 ± 2.0% between 1 and 8 years following surgery. Type 2 diabetes mellitus (T2DM), osteoarthritis-related joint pain and depression/severe anxiety were the most common metabolic, mechanical and mental health comorbidities, with a baseline prevalence of 81.5%, 75.4% and 55.4%, respectively. Clinically significant composite cumulative rates of remission and improvement occurred in T2DM (50.0−82.0%) and hypertension (73.7−82.9%) across 6 years. Dependence on continuous positive airway pressure treatment in patients with sleep-disordered breathing fell significantly from 63.1% to 41.2% in 6 years. Conclusion: Bariatric surgery using an intensive multidisciplinary approach led to significant long-term weight loss and improvement in obesity-related comorbidities among the population with clinically complex obesity. These findings have important implications in clinical care for the management of the highest severity of obesity and its medical consequences. Major challenges associated with successful outcomes of bariatric surgery in highly complex patients include improving mental health in the long run and reducing postoperative opioid use. Long-term follow-up with a higher volume of patients is needed in publicly funded bariatric surgery services to better monitor patient outcomes, enhance clinical data comparison between services, and improve multidisciplinary care delivery.
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Affiliation(s)
- Michelle M.C. Tan
- Boden Initiative, Central Clinical School, Sydney School of Medicine, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia;
- Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Sydney Local Health District, Concord, NSW 2139, Australia
- Diabetes, Metabolism & Obesity Translational Research Unit, Camden Hospital, South Western Sydney Local Health District, Camden, NSW 2570, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW 2050, Australia
| | - Xingzhong Jin
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia;
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, St Leonards, NSW 2064, Australia
| | - Craig Taylor
- Upper GI Surgery Department, Concord Repatriation General Hospital, Sydney Local Health District, Concord, NSW 2139, Australia; (C.T.); (P.L.P.); (D.M.); (D.J.)
| | - Adrian K. Low
- Department of Orthopaedic Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia;
| | - Philip Le Page
- Upper GI Surgery Department, Concord Repatriation General Hospital, Sydney Local Health District, Concord, NSW 2139, Australia; (C.T.); (P.L.P.); (D.M.); (D.J.)
| | - David Martin
- Upper GI Surgery Department, Concord Repatriation General Hospital, Sydney Local Health District, Concord, NSW 2139, Australia; (C.T.); (P.L.P.); (D.M.); (D.J.)
- Hepatobiliary & Upper GIT Surgery Department, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW 2050, Australia
| | - Ang Li
- Boden Initiative, Central Clinical School, Sydney School of Medicine, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia;
- NHMRC Centre of Research Excellence in Healthy Housing, Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC 3010, Australia
| | - David Joseph
- Upper GI Surgery Department, Concord Repatriation General Hospital, Sydney Local Health District, Concord, NSW 2139, Australia; (C.T.); (P.L.P.); (D.M.); (D.J.)
- Hepatobiliary & Upper GIT Surgery Department, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW 2050, Australia
| | - Nic Kormas
- Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Sydney Local Health District, Concord, NSW 2139, Australia
- Diabetes, Metabolism & Obesity Translational Research Unit, Camden Hospital, South Western Sydney Local Health District, Camden, NSW 2570, Australia
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Lehman HS, Diaz S, Dandalides A, Carlin AM. Feasibility of an Opioid Sparing Discharge Protocol Following Laparoscopic Bariatric Surgery. Obes Surg 2022; 32:1-6. [PMID: 35507273 DOI: 10.1007/s11695-022-06094-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/16/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Opioids are commonly prescribed after laparoscopic bariatric surgery but have untoward effects including dependence and diversion. Prior investigation revealed that over three-fourths of discharge opioids prescribed to our patients went unused. OBJECTIVES To determine the feasibility of an opioid sparing discharge protocol following laparoscopic bariatric surgery. METHODS A total of 212 opioid-naïve patients undergoing laparoscopic bariatric surgery were examined and divided into two groups; 106 prior to (Cohort A) and 106 after implementation of an opioid sparing discharge protocol (Cohort B). Opioids were converted to morphine milligram equivalents (MME) and post-operative consumption was examined. Data was described as mean ± standard deviation. RESULTS No patients in Cohort B and 54.7% (58) in Cohort A received an opioid discharge prescription (37.5 MME). Of the 154 patients that remained, only 1.3% (2) received one after discharge. Cohort A took greater amounts of opioids than Cohort B after discharge (4.74 ± 11 vs. 0.21 ± 2 MME; p < 0.001). During hospitalization, Cohort A took greater amounts of opioids (6.92 ± 11 vs. 2.74 ± 5 MME; p < 0.001) but lower amounts of methocarbamol (759 ± 590 vs. 966 ± 585 mg; p = 0.011). No patient requested an opioid prescription refill or presented to the emergency room secondary to pain. CONCLUSION Following laparoscopic bariatric surgery, an opioid sparing discharge protocol is feasible with < 2% of patients receiving opioids after discharge and no increase in emergency room visits. Education regarding these protocols may impact the amount of opioids taken during hospitalization.
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Affiliation(s)
- Haley S Lehman
- Department of Surgery, Henry Ford Macomb Hospital, 15855 19 Mile Road, Clinton Township, MI, 48038, USA.
| | - Sarah Diaz
- Department of Surgery, St. Joseph Mercy Ann Arbor, Ypsilanti, MI, 48917, USA
| | - Alissa Dandalides
- Department of Surgery, Henry Ford Macomb Hospital, 15855 19 Mile Road, Clinton Township, MI, 48038, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health, Detroit, MI, 48202, USA
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Falconer EA, Majumdar MC, Grunewald ZI, Gillingham T, Sanford J, Lane O, Serrot FJ, Stetler J, Patel AD, Srinivasan JK, Sharma J, Davis Jr SS, Lin E, Hechenbleikner EM. A Pilot Study to Increase Transversus Abdominis Plane Block Utilization Among Bariatric Surgeons. Bariatr Surg Pract Patient Care 2022. [DOI: 10.1089/bari.2021.0100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Elissa A. Falconer
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Melissa C. Majumdar
- Office of Quality and Risk, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Zachary I. Grunewald
- Office of Quality and Risk, Emory Johns Creek Hospital, Johns Creek, Georgia, USA
| | - Trent Gillingham
- Office of Quality and Risk, Emory Healthcare, Atlanta, Georgia, USA
| | - Jay Sanford
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Olabisi Lane
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Federico J. Serrot
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jamil Stetler
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ankit D. Patel
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jahnavi K. Srinivasan
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jyotirmay Sharma
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - S. Scott Davis Jr
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edward Lin
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Elizabeth M. Hechenbleikner
- Department of Surgery, Division of General and GI Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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20
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Dudash M, Saeed K, Wang S, Johns A, Colonie R, Falvo A, Horsley R, Gabrielsen J, Petrick AT, Parker DM. A comparative evaluation of robotic and laparoscopic Roux-en-Y gastric bypass: a critical evaluation on the impact of postoperative pain and opioid requirements. Surg Endosc 2022; 36:7700-7708. [PMID: 35199202 DOI: 10.1007/s00464-022-09124-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/07/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The benefits of minimally invasive surgery using laparoscopy on postoperative pain and opioid use are well established. Our goal was to determine whether patients who underwent Roux-en-Y gastric bypass using a robotic approach (RA-RYGB) had lower postoperative pain and required less opioids than those undergoing laparoscopic Roux-en-Y gastric bypass (L-RYGB). Secondary outcomes evaluated included length of stay, operative time, and readmissions. METHODS AND PROCEDURES This was a retrospective cohort study from a tertiary academic medical center. Patients who underwent L-RYGB or RA-RYGB between 5/1/2018 and 10/31/2019 were included. Cases with concomitant hernia repair, chronic opioid use, and those who did not receive a TAP block or multimodal pain control were excluded. Baseline demographics were compared. Inpatient and outpatient opioid use in Morphine Milligram Equivalents (MME) and pain scores (10-point Likert scale) were compared. RESULTS There were 573 RY patients included (462 L-RYGB; 111 RA-RYGB). Median and maximum inpatient pain scores were similar for L-RYGB and RA-RYGB (3.0 vs 3.1, p = 0.878; 7.0 vs 7.0, p = 0.688). Median inpatient opioid use and maximum single day use were similar for L-RYGB and RA-RYGB (40.0 MME vs. 42.0 MME, p = 0.671; 30.0 MME vs 30.0 MME, p = 0.648). Both the outpatient prescribing of opioids (50.2% vs. 42.3%, p = 0.136) and outpatient opioid MME at 2 weeks (L-RYGB 30.0 MME vs. 33.8 MME, p = 0.854) were comparable between cohorts. Patient reported pain at 2-week follow-up was significantly higher for RA-RYGB (68.1%) than L-RYGB (55.6%) (p = 0.030). RA-RYGB had a higher rate of 30-day readmission and longer operative times compared to the L-RYGB (6.3% vs 13.5%, p = 0.010; 144.5 vs 200.0 min, p < 0.001). CONCLUSION This study identified no benefit for postoperative pain or opioid requirements in patients undergoing RA-RYGB compared to L-RYGB. The RA-RYGB group was significantly more likely to report pain at the two-week follow-up.
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Affiliation(s)
- Mark Dudash
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - Kashif Saeed
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - Shengxuan Wang
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - Alicia Johns
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - Ryan Colonie
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - Alexandra Falvo
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - Ryan Horsley
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - Jon Gabrielsen
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - Anthony T Petrick
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA
| | - David M Parker
- Department of General Surgery, Geisinger Medical Center, 100 N. Academy Ave, MC 21-69, Danville, PA, 17822, USA.
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21
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Hospital opioid use predicts the need for discharge opioid prescriptions following laparoscopic bariatric surgery. Surg Endosc 2022; 36:6312-6318. [PMID: 35024936 DOI: 10.1007/s00464-022-09035-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/03/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Overprescribing of opioids after surgery increases new persistent opioid use and diversion contributing to the opioid epidemic. There is a paucity of evidence regarding discharge opioid prescribing after bariatric surgery. METHODS We conducted a retrospective, cohort study analyzing post-operative opioid use at a single institution in patients who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LGB) from July 2019 thru February 2020. Multimodal analgesia was used including 5 mg oxycodone pills as needed during hospitalization with five prescribed on discharge if requested after discussion. Opioid use was determined from medical record review and post-operative data collected from patients at a 2-week follow-up visit. The Michigan Automated Prescription System (MAPS) was used as an adjunct to evaluate perioperative opioid prescriptions. RESULTS The cohort of 84 patients included those having LSG (72) and LGB (12). Fifty-five patients (65%) received a prescription for opioids on discharge and 91% filled their prescription. Only 44% (22/50) of those filling their opioid prescription took any opioids with 24% (65/275) of the total pills prescribed actually consumed. Opioid use on the surgical ward had the strongest correlation with discharge opioid use (rho = 0.65, CI 0.494, 0.770). The number of opioid pills taken on the surgical ward was positively associated with the number of pills taken after discharge. Those who took none, 1 to 3, or 4 or more opioid pills consumed 0.14 ± 0.48, 0.95 ± 1.71, and 3.14 ± 1.86 pills after discharge (p < 0.001). No patients required an additional opioid prescription within 90 days of surgery with MAPS confirmation. CONCLUSION Postoperative in-hospital opioid use following laparoscopic bariatric surgery predicts opioid use after discharge. This knowledge can guide patient-specific discharge opioid prescribing with the potential to mitigate diversion and reduce chronic opioid use.
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22
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Implementation of an enhanced recovery after surgery protocol for bariatric surgery - A qualitative study. Am J Surg 2022; 224:465-469. [DOI: 10.1016/j.amjsurg.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/17/2021] [Accepted: 01/19/2022] [Indexed: 12/20/2022]
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Coughlin JW, Steffen KJ, Sockalingam S, Mitchell JE. Psychotropic Medications in Metabolic and Bariatric Surgery: Research Updates and Clinical Considerations. Curr Psychiatry Rep 2022; 24:89-98. [PMID: 35076886 DOI: 10.1007/s11920-022-01317-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW We review evidence for assessing and monitoring psychotropic medications in metabolic and bariatric surgery (MBS) patients. We describe weight gain side effects, potential perioperative risks, pharmacokinetic changes that occur after MBS, and conclude with clinical recommendations. RECENT FINDINGS Research on psychiatric medication use and post-MBS weight outcomes is lacking and inconsistent; however, there is consistent evidence that, though variable, psychiatric medication use is associated with weight gain. Several meta-analyses and reviews provide guidance on lowering risk when appropriate. Perioperative lithium toxicity and SSRI discontinuation syndrome also warrant consideration, as do potential post-operative pharmacokinetic changes. In the absence of data for each psychiatric drug classification, close symptom monitoring and, where appropriate, serum concentration monitoring are recommended. MBS patients are a psychiatrically vulnerable population, and many are on psychiatric medications. Given potential weight/metabolic side effects, perioperative complications, and post-operative pharmacokinetic changes that occur with psychotropic medication use, providers should stay well informed on psychiatric medication management considerations.
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Affiliation(s)
- Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, MD, 21224, Baltimore, USA.
| | - Kristine J Steffen
- North Dakota State University, College of Health Professions, ND, 58103, Fargo, USA.,Sanford Center for Biobehavioral Research, ND, 58103, Fargo, USA
| | - Sanjeev Sockalingam
- University Health Network Bariatric Surgery Program Centre for Addiction and Mental Health University of Toronto, ON, M6J 1H4, Toronto, Canada
| | - James E Mitchell
- Sanford Center for Biobehavioral Research, ND, 58103, Fargo, USA.,University of North Dakota School of Medicine and Health Sciences, ND, 58103, Fargo, USA
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Quraishi SA, Seth S, Gonzalez-Ciccarelli LF, Dahlawi M, Ferrufino R, Shah SN, Schumann R. The association of sex with pain scores and perioperative opioid administration following laparoscopic sleeve gastrectomy. Pain Manag 2021; 12:425-433. [PMID: 34886678 DOI: 10.2217/pmt-2021-0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: We investigated whether sex is associated with pain scores and opioid administration after laparoscopic sleeve gastrectomy. Materials & methods: We performed a single-center, retrospective analysis of laparoscopic sleeve gastrectomy patients from December 2016-July 2018. Multivariable linear regressions were performed to investigate the association of sex with pain scores and opioid administration. Results: Baseline pain scores were similar between women and men (n = 266; 78% women). Men reported lower pain scores in all phases of care and received more opioids during their hospitalization (ß = 25.48; 95% CI: 5.77-45.20; p = 0.01), compared with women. Conclusion: Our data suggest that women self-report greater postoperative pain scores, while men received more opioids during their hospitalization. Further studies are needed to understand the reasons for such differences in postoperative pain management.
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Affiliation(s)
- Sadeq A Quraishi
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Box 298, 800 Washington St, Boston, MA 02111, USA.,Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA
| | - Sonika Seth
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Box 298, 800 Washington St, Boston, MA 02111, USA
| | | | - Mohammad Dahlawi
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Box 298, 800 Washington St, Boston, MA 02111, USA
| | - Renan Ferrufino
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Box 298, 800 Washington St, Boston, MA 02111, USA
| | - Sajani N Shah
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA.,Department of Surgery, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Roman Schumann
- Department of Anesthesiology & Perioperative Medicine, Tufts Medical Center, Box 298, 800 Washington St, Boston, MA 02111, USA.,Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA.,Department of Anesthesiology, Critical Care & Pain Medicine, VA Boston Medical Center, West Roxbury, MA 02132, USA
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25
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Converging vulnerability factors for compulsive food and drug use. Neuropharmacology 2021; 196:108556. [PMID: 33862029 DOI: 10.1016/j.neuropharm.2021.108556] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/29/2021] [Accepted: 04/03/2021] [Indexed: 12/12/2022]
Abstract
Highly palatable foods and substance of abuse have intersecting neurobiological, metabolic and behavioral effects relevant for understanding vulnerability to conditions related to food (e.g., obesity, binge eating disorder) and drug (e.g., substance use disorder) misuse. Here, we review data from animal models, clinical populations and epidemiological evidence in behavioral, genetic, pathophysiologic and therapeutic domains. Results suggest that consumption of highly palatable food and drugs of abuse both impact and conversely are regulated by metabolic hormones and metabolic status. Palatable foods high in fat and/or sugar can elicit adaptation in brain reward and withdrawal circuitry akin to substances of abuse. Intake of or withdrawal from palatable food can impact behavioral sensitivity to drugs of abuse and vice versa. A robust literature suggests common substrates and roles for negative reinforcement, negative affect, negative urgency, and impulse control deficits, with both highly palatable foods and substances of abuse. Candidate genetic risk loci shared by obesity and alcohol use disorders have been identified in molecules classically associated with both metabolic and motivational functions. Finally, certain drugs may have overlapping therapeutic potential to treat obesity, diabetes, binge-related eating disorders and substance use disorders. Taken together, data are consistent with the hypotheses that compulsive food and substance use share overlapping, interacting substrates at neurobiological and metabolic levels and that motivated behavior associated with feeding or substance use might constitute vulnerability factors for one another. This article is part of the special issue on 'Vulnerabilities to Substance Abuse'.
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26
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Namiranian K, Siglin J, Sorkin JD. The incidence of persistent postoperative opioid use among U.S. veterans: A national study to identify risk factors. J Clin Anesth 2020; 68:110079. [PMID: 33010491 DOI: 10.1016/j.jclinane.2020.110079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/23/2020] [Accepted: 09/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To calculate the incidence and identify the predictors of persistent postoperative opioid use at different postoperative days. BACKGROUND DATA A subset of surgical patients continues to use long-term opioids. The importance of the risk factors at different postoperative days is not known. DESIGN A historical cohort. SETTING Postoperative period. PATIENTS Opioid-naive U.S. veterans. INTERVENTIONS The surgical group had any one of 19 common invasive procedures. The control group is a 10% random sample. Each control was randomly assigned a surgery date. MEASUREMENTS The outcomes were the presence of persistent opioid use as determined by continued filling of prescriptions for opioids on postoperative days 90, 180, 270, and 365. MAIN RESULTS A total of 183,430 distinct surgical cases and 1,318,894 controls were identified. 1.0% of the surgical patients were using opioids at 90 days, 0.6% at 180 days, 0.4% at 270 days, and 0.1% at 365 days after the surgery. Surgery was strongly associated with postoperative persistent opioid use at day 90 (OR 3.67, 95% CI, 3.43-3.94, p < 0.001), at day 180 (OR 2.85, 2.67-3.12, p < 0.001), at day 270 (OR 2.63, 2.38-2.91, p < 0.001) and at day 365 (OR 2.11, 1.77-2.51, p < 0.001) compared to non-surgical controls. In risk factor analysis, being male and single were associated with persistent opioid use at earlier time points (90 and 180 days), while hepatitis C and preoperative benzodiazepine use were associated with persistent opioid use at later time points (270 and 365 days). CONCLUSIONS Many surgeries or invasive procedures are associated with an increased risk of persistent postoperative opioid use. The postoperative period is dynamic and the risk factors change with time.
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Affiliation(s)
- Khodadad Namiranian
- VA Maryland Health Care System, Baltimore, MD, United States of America; Department of Anesthesiology, University of Maryland, Baltimore, MD, United States of America; VA Central California Health Care System, Fresno, CA, United States of America.
| | - Jonathan Siglin
- School of Medicine, University of Maryland, Baltimore, MD, United States of America
| | - John David Sorkin
- VA Maryland Health Care System, Baltimore, MD, United States of America; Baltimore VA Medical Center Geriatric Research, Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States of America; Division of Gerontology and Geriatric Medicine, University of Maryland, Baltimore, MD, United States of America
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27
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Pardue B, Thomas A, Buckley J, Suggs WJ. An Opioid-Sparing Protocol Improves Recovery Time and Reduces Opioid Use After Laparoscopic Sleeve Gastrectomy. Obes Surg 2020; 30:4919-4925. [PMID: 32951136 DOI: 10.1007/s11695-020-04980-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 09/12/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The current literature is sparse on post discharge pain management for bariatric surgical patients. This study aimed to determine if an opioid-sparing protocol could decrease opioid use during the postoperative period (hospital to home). MATERIALS AND METHODS In this retrospective cohort study, we implemented an opioid-sparing protocol in January 2018, for patients undergoing laparoscopic sleeve gastrectomy (LSG) at our institution. We compared recovery time, pain scores (in hospital and at home), and perioperative opioid use between the historic control group (February 2017 to December 2017) and the opioid-sparing group (January 2018 to December 2018). A p value of < .05 was considered statistically significant. RESULTS The study included 400 patients (200 in each group), and 165 participated in the phone survey. Baseline characteristics were similar, except the control group had a higher body mass index and body weight. The average recovery time was significantly shorter in the opioid-sparing group (18.9 versus 35.3 days, P = .043). There was no significant difference in mean postoperative pain scores in the hospital or at home. The opioid-sparing group required significantly fewer opioids postoperatively (10.4 versus 16.1 morphine milligram equivalents, P < .001). Only 1 out of the 200 patients in the opioid-sparing arm requested an opioid prescription after discharge. CONCLUSION Implementation of an opioid-sparing protocol improved recovery time and reduced postoperative opioid use in the hospital and after discharge without changing perceived pain in patients undergoing LSG.
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Affiliation(s)
- Benjamin Pardue
- Edward Via College of Osteopathic Medicine - Auburn Campus, 910 South Donahue Drive, Auburn, AL, 36832, USA
| | - Austin Thomas
- Edward Via College of Osteopathic Medicine - Auburn Campus, 910 South Donahue Drive, Auburn, AL, 36832, USA
| | - Jake Buckley
- Crestwood Medical Center, One Hospital Drive, Huntsville, AL, 35801, USA
| | - William J Suggs
- Crestwood Medical Center, One Hospital Drive, Huntsville, AL, 35801, USA.
- Alabama Bariatrics, 705 Bank Street, Decatur, AL, 35601, USA.
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Gormsen J, Gögenur I, Helgstrand F. Quality of life and occupational outcomes after laparoscopic Roux-en-Y gastric bypass surgery. Surgery 2020; 168:471-477. [DOI: 10.1016/j.surg.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/30/2020] [Accepted: 04/03/2020] [Indexed: 12/27/2022]
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29
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Maciejewski ML, Smith VA, Berkowitz TSZ, Arterburn DE, Bradley KA, Olsen MK, Liu CF, Livingston EH, Funk LM, Mitchell JE. Long-term opioid use after bariatric surgery. Surg Obes Relat Dis 2020; 16:1100-1110. [PMID: 32507657 PMCID: PMC7423624 DOI: 10.1016/j.soard.2020.04.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/03/2020] [Accepted: 04/22/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Opioid analgesics are often prescribed to manage pain after bariatric surgery, which may develop into chronic prescription opioid use (CPOU) in opioid-naïve patients. Bariatric surgery may affect opioid use in those with or without presurgical CPOU. OBJECTIVE To compare CPOU persistence and incidence in a large multisite cohort of veterans undergoing bariatric surgery (open Roux-en-Y gastric bypass, laparoscopic RYGB, or laparoscopic sleeve gastrectomy) and matched nonsurgical controls. SETTING Veterans Administration hospitals. METHODS In a retrospective cohort study, we matched 1117 surgical patients with baseline CPOU to 9531 nonsurgical controls, and 2822 surgical patients without CPOU at baseline to 26,392 nonsurgical controls using sequential stratification. CPOU persistence in veterans with baseline CPOU was estimated using generalized estimating equations by procedure type. CPOU incidence in veterans without baseline CPOU was estimated in Cox regression models by procedure type because postoperative pain, complications, and absorption may differ by procedure. RESULTS In veterans with baseline CPOU, postsurgical CPOU declined over time for each surgical procedure; these trends did not differ between surgical patients and nonsurgical controls. In veterans without baseline CPOU, compared with nonsurgical controls, bariatric patients had higher CPOU incidence within 5 years after open Roux-en-Y gastric bypass (hazard ratio = 1.19; 95% confidence interval: 1.06-1.34) or laparoscopic open Roux-en-Y gastric bypass (hazard ratio = 1.22, 95% confidence interval: 1.06-1.41). Veterans undergoing laparoscopic sleeve gastrectomy had higher CPOU incidence 1 to 5 years after surgery (hazard ratio = 1.28; 95% confidence interval: 1.05-1.56) than nonsurgical controls. CONCLUSIONS Bariatric surgery was associated with greater risk of CPOU incidence in patients without baseline CPOU but was not associated with greater CPOU persistence.
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Affiliation(s)
- Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina; Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina.
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina; Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Theodore S Z Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington; Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
| | - Maren K Olsen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Chuan-Fen Liu
- Department of Health Services, University of Washington, Seattle, Washington
| | - Edward H Livingston
- Veterans Administration North Texas Healthcare System, Dallas, Texas; Department of Surgery, University of California at Los Angeles, Los Angeles, California; Division of General Surgery, Northwestern University, Evanston, Illinois; Journal of the American Medical Association, Chicago, Illinois
| | - Luke M Funk
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin; William S. Middleton Veterans Memorial Hospital, Madison, Wisconsin
| | - James E Mitchell
- University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota
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Clement KC, Canner JK, Whitman GJR, Lawton JS, Grant MC, Sussman MS. New Persistent Opioid Use After Aortic and Mitral Valve Surgery in Commercially Insured Patients. Ann Thorac Surg 2020; 110:829-835. [PMID: 32004502 DOI: 10.1016/j.athoracsur.2019.12.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/15/2019] [Accepted: 12/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deaths from prescription opioid overdose are dramatically increasing. This study evaluates the incidence, risk factors, and cost of new persistent opioid use after aortic valve replacement, mitral valve replacement, and mitral valve repair. METHODS Insurance claims from commercially insured patients who underwent aortic valve replacement, mitral valve replacement, mitral valve repair, or aortic valve replacement and mitral valve replacement/repair from 2014 to 2016 were evaluated. New persistent opioid use was defined as opioid-naive patients who filled an opioid prescription in the perioperative period and filled opioid prescriptions between 90 and 180 days postoperatively. Multivariable logistic regression identified risk factors for new persistent opioid use. Quantile regression evaluated the impact of new persistent opioid use on total healthcare payments in the 6 months after discharge. RESULTS Among 3404 opioid-naive patients undergoing aortic valve replacement, mitral valve replacement, or mitral valve repair, 188 (5.5%) had new persistent opioid use. Living in the southern United States (odds ratio, 1.89; 95% confidence interval, 1.35-2.63; P < .001) and increased opioids prescribed in the perioperative period (odds ratio, 1.009; 95% confidence interval, 1.006-1.012; P < .001) were independently associated with new persistent opioid use. After risk adjustment, new persistent opioid use was associated with a 2-fold higher number of emergency department visits (odds ratio, 2.21; 95% confidence interval, 1.61-3.03; P < .001) and a $5422 increase in healthcare payments in the 6 months after discharge. CONCLUSIONS New persistent opioid use is a significant and costly complication after aortic and mitral valve surgery in privately insured patients. Variation in regional susceptibility and opioid prescribing suggests that standardization may help prevent this complication.
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Affiliation(s)
- Kathleen C Clement
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael C Grant
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc S Sussman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ehlers AP, Sullivan KM, Stadeli KM, Monu JI, Chen-Meekin JY, Khandelwal S. Opioid Use Following Bariatric Surgery: Results of a Prospective Survey. Obes Surg 2019; 30:1032-1037. [PMID: 31808115 DOI: 10.1007/s11695-019-04301-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioid use after bariatric surgery is not clearly understood. Few guidelines exist to inform opioid-prescribing practices after bariatric surgery. OBJECTIVE To understand opioid use following bariatric surgery. SETTING University hospital. METHODS Bariatric surgery patients at a single center were prospectively surveyed at the time of their post-operative visit (January-May 2018). Patients were asked about their opioid use following surgery, whether they received education about opioid use and what they did with leftover medications. Demographic and operative details were obtained from the medical record. RESULTS Among 33 patients, the majority (n = 29, 88%) were female with a median age of 40 (20-68) and body mass index of 44.8 (33-78.5). Most patients had leftover narcotics (n = 25, 73%). The median number of pills used was 15 (0-48). Only 12 patients (36%) thought that they had been prescribed "too much" pain medication. Most patients reported receiving education about expectations for post-operative pain (n = 22, 69%); few recalled education about reducing or stopping opioids (n = 13, 40%). More than half of patients (n = 17, 53%) kept their leftover opioids rather than disposing of them or bringing them to an approved turn in location. CONCLUSIONS Despite most patients having leftover opioids following surgery, few patients recognized possible overprescription. Education regarding opioid use following surgery is inconsistent, potentially contributing to the amount of retained opioids currently available. Future guidelines should focus on determining the appropriate amount of opioids to be prescribed following surgery and standardizing and improving education given to patients.
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Affiliation(s)
- Anne P Ehlers
- Department of Surgery, University of Michigan, VA Ann Arbor Healthcare System 2210 Taubman Center, SPC 5343, Ann Arbor, MI, USA.
| | - Kevin M Sullivan
- Department of Surgery, University of Washington, Seattle, WA, USA
| | | | - John I Monu
- Department of Surgery, University of Washington, Seattle, WA, USA
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Simoni AH, Ladebo L, Christrup LL, Drewes AM, Johnsen SP, Olesen AE. Chronic abdominal pain and persistent opioid use after bariatric surgery. Scand J Pain 2019; 20:239-251. [DOI: 10.1515/sjpain-2019-0092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/17/2019] [Indexed: 12/13/2022]
Abstract
Abstract
Background and aims
Bariatric surgery remains a mainstay for treatment of morbid obesity. However, long-term adverse outcomes include chronic abdominal pain and persistent opioid use. The aim of this review was to assess the existing data on prevalence, possible mechanisms, risk factors, and outcomes regarding chronic abdominal pain and persistent opioid use after bariatric surgery.
Methods
PubMed was screened for relevant literature focusing on chronic abdominal pain, persistent opioid use and pharmacokinetic alterations of opioids after bariatric surgery. Relevant papers were cross-referenced to identify publications possibly not located during the ordinary screening.
Results
Evidence regarding general chronic pain status after bariatric surgery is sparse. However, our literature review revealed that abdominal pain was the most prevalent complication to bariatric surgery, presented in 3–61% of subjects with health care contacts or readmissions 1–5 years after surgery. This could be explained by behavioral, anatomical, and/or functional disorders. Persistent opioid use and doses increased after bariatric surgery, and 4–14% initiated a persistent opioid use 1–7 years after the surgery. Persistent opioid use was associated with severe pain symptoms and was most prevalent among subjects with a lower socioeconomic status. Alteration of absorption and distribution after bariatric surgery may impact opioid effects and increase the risk of adverse events and development of addiction. Changes in absorption have been briefly investigated, but the identified alterations could not be separated from alterations caused solely by excessive weight loss, and medication formulation could influence the findings. Subjects with persistent opioid use after bariatric surgery achieved lower weight loss and less metabolic benefits from the surgery. Thus, remission from comorbidities and cost effectiveness following bariatric surgery may be limited in these subjects.
Conclusions
Pain, especially chronic abdominal, and persistent opioid use were found to be prevalent after bariatric surgery. Physiological, anatomical, and pharmacokinetic changes are likely to play a role. However, the risk factors for occurrence of chronic abdominal pain and persistent opioid use have only been scarcely examined as have the possible impact of pain and persistent opioid use on clinical outcomes, and health-care costs. This makes it difficult to design targeted preventive interventions, which can identify subjects at risk and prevent persistent opioid use after bariatric surgery. Future studies could imply pharmacokinetic-, pharmacodynamics-, and physiological-based modelling of pain treatment. More attention to social, physiologic, and psychological factors may be warranted in order to identify specific risk profiles of subjects considered for bariatric surgery in order to tailor and optimize current treatment recommendations for this population.
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Affiliation(s)
- Amalie H. Simoni
- Danish Center for Clinical Health Service Research (DACS), Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - Louise Ladebo
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
| | - Lona L. Christrup
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology , University of Copenhagen , Copenhagen , Denmark
| | - Asbjørn M. Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
| | - Søren P. Johnsen
- Danish Center for Clinical Health Service Research (DACS), Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - Anne E. Olesen
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- Department of Clinical Pharmacology , Aalborg University Hospital , Gartnerboligen, Ground Floor, Mølleparkvej 8a , 9000 Aalborg , Denmark , Phone: +45 97664376
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Clement KC, Canner JK, Lawton JS, Whitman GJR, Grant MC, Sussman MS. Predictors of new persistent opioid use after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2019; 160:954-963.e4. [PMID: 32007246 DOI: 10.1016/j.jtcvs.2019.09.137] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/26/2019] [Accepted: 09/03/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Deaths from prescription opioid overdose have quadrupled in the past 15 years, and no studies have evaluated appropriate opioid prescribing after cardiac surgery. The aim of this study is to quantify the amount of outpatient opioids prescribed to patients after coronary artery bypass grafting and determine the incidence and risk factors for new persistent opioid use after coronary artery bypass grafting. METHODS Insurance claim data from privately insured opioid-naïve patients who underwent coronary artery bypass grafting from 2014 to 2016 were evaluated. New persistent opioid use was defined as patients who filled an opioid prescription in the perioperative period and filled opioid prescriptions between 90 and 180 days after surgery. Multivariable logistic regression was used to determine the preoperative and operative factors associated with new persistent opioid use. RESULTS Among 7292 opioid-naïve patients undergoing coronary artery bypass grafting, 5628 (77.2%) filled opioid prescriptions in the perioperative period, and 590 (8.1%) had new persistent opioid use. Female gender (odds ratio [OR], 1.30; confidence interval [CI], 1.05-1.61; P = .018), anxiety (OR, 1.40; CI, 1.09-1.81; P = .009), tobacco use (OR, 1.34; CI, 1.08-1.65; P = .007), prior substance abuse (OR, 1.99; CI, 1.16-3.41; P = .013), chronic obstructive pulmonary disease (OR, 1.29; CI, 1.02-1.63; P = .037), living in the Southern United States (OR, 1.46; CI, 1.21-1.77; P < .001), and increased amount of opioids prescribed in the perioperative period (OR, 1.016; CI, 1.014-1.018; P < .001) were independently associated with new persistent opioid use. CONCLUSIONS New persistent opioid use after coronary artery bypass grafting is surprisingly common. Prospective studies are needed to determine the opioid requirements of patients after coronary artery bypass grafting to prevent opioid dependence.
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Affiliation(s)
- Kathleen C Clement
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Michael C Grant
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Marc S Sussman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS). Surg Endosc 2019; 34:2184-2190. [DOI: 10.1007/s00464-019-07006-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/19/2019] [Indexed: 12/19/2022]
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