Chronic opioid use after coronary bypass surgery

Efficacy of opioid-sparing analgesia after median sternotomy with continuous bilateral parasternal subpectoral plane blocks

OBJECTIVES

Regional anesthetic techniques, traditionally underutilized in cardiac surgery, may play a role in multimodal analgesia, effectively improving pain control and reducing opioid consumption. We investigated the efficacy of continuous bilateral ultrasound-guided parasternal subpectoral plane blocks following sternotomy.

METHODS

We reviewed all opioid-naïve patients who underwent cardiac surgery via median sternotomy under our enhanced recovery after surgery protocol between May 2018 and March 2020. Patients were grouped based on postoperative pain management strategy-those who received standard Enhanced Recovery After Surgery (ERAS) multimodal analgesia alone (no nerve block group) versus those receiving ERAS multimodal analgesia plus continuous bilateral parasternal subpectoral plane blocks (block group). In the block group, parasternal subpectoral plane catheters were placed under ultrasound-guidance on each side of the sternum with initial 0.25% ropivacaine bolus, followed by continuous 0.125% bupivacaine infusions. Postoperative patient-reported numerical rating scale pain scores and opioid consumption in morphine milligram equivalents were compared through postoperative day 4.

RESULTS

Of 281 patients included in the study, the block group comprised 125 (44%) patients. Although baseline characteristics, type of surgery, and length of stay were similar between groups, average numerical rating scale pain scores and opioid consumption were significantly lower in the block group through postoperative day 4 (all P values < .05). We also observed a 44% reduction in total opioid consumption after surgery in the block group (75.1 vs 133.1 MME; P = .001) and 1 less hospital day requiring opioids (4.2 vs 3 days; P = .001).

CONCLUSIONS

Continuous bilateral parasternal subpectoral plane blocks may further reduce poststernotomy pain and opioid consumption within the context ERAS multimodal analgesia.

Evaluating the Efficacy of the Erector Spinae Plane Block as a Supplementary Approach to Cardiac Anesthesia during Off-Pump Coronary Bypass Graft Surgery via Median Sternotomy: A Randomized Clinical Trial

Background: Pain control after off-pump coronary artery bypass graft (OPCAB) facilitates mobilization and improves outcomes. The efficacy of the erector spinae plane block (ESPB) after cardiac surgery remains controversial. Methods: We aimed to investigate the analgesic effects of ESPB after OPCAB. Precisely 56 patients receiving OPCAB were randomly divided into ESPB and control groups. The primary outcome was visual analog scale (VAS) pain scores at 6, 12, 24, and 48 h postoperatively. Secondary outcomes were the dose of rescue analgesics in terms of oral morphine milligram equivalents, the dose of antiemetics, the length of intubation time, and the length of stay in the intensive care unit (ICU). Results: The VAS scores were similar at all time points in both groups. The incidence of severe pain (VAS score > 7) was significantly lower in the ESPB group (50% vs. 15.4%; p = 0.008). The dose of rescue analgesics was also lower in the ESPB group (19.04 ± 18.76, 9.83 ± 12.84, p = 0.044) compared with the control group. The other secondary outcomes did not differ significantly between the two groups. Conclusions: ESPB provides analgesic efficacy by reducing the incidence of severe pain and opioid use after OPCAB.

Hospital and long-term opioid use according to analgosedation with fentanyl vs. morphine: Findings from the ANALGESIC trial

Objectives

Opioid use disorder is extremely common. Many long-term opioid users will have their first exposure to opioids in hospitals. We aimed to compare long-term opioid use in patients who received fentanyl vs. morphine analgosedation and assess ICU related risk factors for long-term opioid use.

Design

We performed a post-hoc analysis of the Assessment of Opioid Administration to Lead to Analgesic Effects and Sedation in Intensive Care (ANALGESIC) cluster randomised crossover trial of fentanyl and morphine infusions for analgosedation in mechanically ventilated patients.

Setting

Two mixed, adult, university affiliated intensive care units in Melbourne, Australia.

Participants

Adult patients who were mechanically ventilated and received fentanyl or morphine for analgosedation in the ANALGESIC trial.

Main outcome measures

We assessed discharge and long-term (90-365 days) opioid use in opioid-naïve patients at hospital admission according to the agent used for analgosedation.

Results

We studied 477 patients (242 fentanyl and 235 morphine). There were no differences between discharge (16.5% vs. 14.0%, p = 0.45), 90-180 day post-discharge use (3.7% vs 2.1%, p = 0.30) or 180-365 day post-discharge use (3.4% vs 1.3%, p = 0.22) of opioids when comparing those patients who received fentanyl vs. those who received morphine. Surgical diagnosis and one chronic condition were associated with increased hospital discharge prescription of opioids, whereas increasing APACHE II score was associated with decreased discharge prescription. No ICU-related factors were associated with long-term opioid use.

Conclusions

Approximately one in seven opioid-naïve patients who receive analgosedation for mechanical ventilation in ICU will be prescribed opioid medications at hospital discharge. There was no difference in discharge prescription or long-term use of opioids depending on whether fentanyl or morphine was used for analgosedation.

Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.

Peripheral Regional Anesthesia Using Local Anesthetics: Old Wine in New Bottles?

During the past decade, numerous efforts were undertaken aiming at prolonging the analgesic effect of regional anesthesia. With the development of extended-release formulations and enhanced selectivity for nociceptive sensory neurons, a very promising contribution to the development of pain medications has been achieved. At present, liposomal bupivacaine is the most popular, non-opioid, controlled drug delivery system, but its duration of action, which is still controversially discussed, and its expensiveness have decreased initial enthusiasm. Continuous techniques can be seen as an elegant alternative for providing a prolonged duration of analgesia, but for logistic or anatomical reasons, they are not always the best choice. Therefore, focus has been directed towards the perineural and/or intravenous addition of old and established substances. As for perineural application, most of these so-called 'adjuvants' are used outside their indication, and their pharmacological efficacy is often not or only poorly understood. This review aims to summarize the recent developments for prolonging the duration of regional anesthesia. It will also discuss the potential harmful interactions and side effects of frequently used analgesic mixtures.

Epidemiology of persistent postoperative opioid use after cardiac surgery: a systematic review and meta-analysis

BACKGROUND

The epidemiology of persistent postoperative opioid use at least 3 months after cardiac surgery is poorly characterised despite its potential public health importance.

METHODS

We searched MEDLINE, Embase, and Google Scholar from inception to December 2021 and included studies reporting the rate and risk factors of persistent postoperative opioid use after cardiac surgery in opioid-naive and opioid-exposed patients. We recorded incidence rates and odds ratios (ORs) with 95% confidence intervals (CIs) for risk factors from individual studies and used random-effects inverse variance modelling to generate pooled estimates.

RESULTS

From 10 studies involving 112 298 patients, the pooled rate of persistent postoperative opioid use in opioid-naive patients was 5.7% (95% CI: 4.2-7.2%). Risk factors included female sex (OR 1.18; 95% CI: 1.09-1.29), smoking (OR 1.34; 95% CI: 1.06-1.69), alcohol use (OR 1.43; 95% CI: 1.17-1.76), congestive cardiac failure (OR 1.17; 95% CI: 1.08-1.27), diabetes mellitus (OR 1.21; 95% CI: 1.07-1.37), chronic lung disease (OR 1.42; 95% CI: 1.16-1.75), chronic kidney disease (OR 1.35; 95% CI: 1.08-1.68), and length of hospital stay (per day) (OR 1.03; 95% CI: 1.02-1.04).

CONCLUSIONS

Persistent postoperative opioid use after cardiac surgery affects at least one in 20 patients. The identification of risk factors, such as female sex, smoking, alcohol use, congestive cardiac failure, diabetes mellitus, chronic lung disease, chronic kidney disease, and length of hospital stay, should help target interventions aimed at decreasing its prevalence.

Patient and caregiver preferences and prioritized outcomes for cardiac surgery: A scoping review and consultation workshop

OBJECTIVE(S)

In light of the absence of patient and caregiver input in Enhanced Recovery After Surgery Cardiac Surgery guideline development, we conducted a scoping review to identify patient and caregiver preferences and prioritized outcomes related to perioperative care in cardiac surgery and its lifelong impact.

METHODS

Five electronic databases were searched to retrieve studies investigating patient or caregiver preferences and prioritized outcomes. Information was charted in duplicate and analyzed using descriptive statistics or thematic analysis. A patient and caregiver consultation workshop validated scoping review findings and solicited novel preferences and outcomes.

RESULTS

Of the 5292 articles retrieved, 43 met inclusion criteria. Most were from Europe (n = 19, 44%) or North America (n = 15, 35%) and qualitative and quantitative designs were represented in equal proportions. Fifty-two methods were used to obtain stakeholder preferences and prioritized outcomes, the majority being qualitative in nature (n = 32, 61%). Based on the collective preferences of 3772 patients and caregivers from the review and 17 from the consultation workshop, a total of 108 patient preferences, 32 caregiver preferences, and 19 prioritized outcomes were identified. The most commonly identified theme was "information and education." Improved quality of life was the most common patient-prioritized outcome, and all caregiver-prioritized outcomes were derived from the consultation workshop.

CONCLUSIONS

Patient and caregiver preferences overlap with Enhanced Recovery After Surgery Cardiac Surgery recommendations targeting preoperative risk reduction strategies, prehabilitation, patient engagement technology, and intra- and postoperative strategies to reduce discomfort. To support clinical practice, future research should investigate associations with key surgical outcomes.

Opioid Prescription After Cardiac Surgery

OBJECTIVES

To characterise short-term and long-term opioid prescription patterns after cardiac surgery.

DESIGN, SETTING AND PARTICIPANTS

We obtained data from a single Australian tertiary hospital from November 2012 to July 2019 and included 2,205 patients who underwent a primary cardiac surgical procedure.

MAIN OUTCOME AND MEASURES

The primary outcome was the dose of opioids at hospital discharge. Secondary outcomes included factors associated with high dose opioid prescriptions and persistent opioids use after cardiac surgery.

RESULTS

Overall, 76.4% of study patients were prescribed opioids at hospital discharge, with a median discharge prescription of 150 mg oral morphine equivalents. Moreover, 52.8% of discharge opioid prescriptions were as slow-release formulations and 60.0% of all discharge prescriptions were for patients who had received no opioids the day before discharge. In the subset of our patients with long-term data, 14.0% were still receiving opioids at 3-12 months after cardiac surgery.

CONCLUSIONS

In cardiac surgical patients, opioid prescriptions at discharge were common, most were at higher than recommended doses and more than half were slow-release formulations. Such prescription was associated with one in seven patients continuing to receive opioids 3-12 months after surgery.

Web- and Mindfulness-Based Intervention to Prevent Chronic Pain After Cardiac Surgery: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Cardiac surgery is a frequently performed procedure. However, pain after cardiac surgery may become chronic (lasting >3 months) in adults. Once discharged from the hospital, patients are at greater risk of developing chronic postsurgical pain (CPSP) and of prolonged opioid use, as they need to self-manage their pain. Psychological risk and protective factors such as pain-related catastrophic thoughts and pain acceptance determine their ability to cope and their use of opioids, which is crucial for self-management of pain. Studies on mindfulness-based cognitive therapy (MBCT) have multiplied their potential effects on pain acceptance and catastrophic thoughts. However, web-based MBCT for the prevention of CPSP has not yet been examined.

OBJECTIVE

The aim of this study is to pilot test a 4-week-long web-based MBCT intervention for adults following discharge from the hospital by assessing the acceptability or feasibility of the intervention and examining preliminary effects on pain intensity, pain interference with activities and opioid use, and pain acceptance and catastrophic thoughts in the 6 months following surgery.

METHODS

A double-blinded pilot randomized controlled trial will be used to assess a web-based MBCT intervention. Patients will be selected according to the following criteria: age ≥18 years; first-time elective cardiac surgery via a median sternotomy; worst pain in the past week score ≥4/10; ability to understand and complete questionnaires in English; and ability to use an electronic device such as a smartphone, computer, or tablet. After baseline measures, 32 participants will be randomized into two groups: one receiving both the brief, 4-week-long web-based MBCT intervention and usual care (experimental group) and the other receiving only one standardized, web-based educational session with weekly reminders and usual care (attention control group). Peer-reviewed competitive funding was received from Florida State University's Council on Research & Creativity in January 2021, as well as research ethics approval from Florida State University's institutional review board.

RESULTS

Recruitment began in June 2021. Unfortunately, because of the current COVID-19 pandemic, recruitment is not progressing as expected. Recruitment strategies are constantly monitored and updated according to latest data and restrictions surrounding the pandemic.

CONCLUSIONS

This research is significant because it targets the trajectory of CPSP, a leading cause of disability and opioid misuse. This is the first study to assess MBCT for the prevention of CPSP after cardiac surgery in the recovery phase. This approach is innovative because it promotes self-management of pain through the modulation of individual factors. If successful, the intervention could be expanded to numerous populations at risk of chronic pain.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30951.

Current Status of Neuraxial and Paravertebral Blocks for Adult Cardiac Surgery

Cardiac surgeries are known to produce moderate to severe pain. Pain management has traditionally been based on intravenous opioids. Poorly controlled pain can result in increased incidence of respiratory complications such as atelectasis and pneumonia leading to prolonged intubation and intensive care unit length of stay and subsequent prolonged hospital stay. Adequate perioperative analgesia improves hemodynamics and immunologic responses, which would result in better outcomes after cardiac surgery. Opioid sparing "Enhanced Recovery After Surgery" protocols are increasingly being incorporated into cardiac surgeries. This will reduce opioid requirements and opioid-related side effects and facilitate fast-tracking of patients. Regional analgesia can be provided by neuraxial blocks, fascial plane blocks, peripheral nerve blocks, or simply by the infiltration of the wound with local anesthetics for cardiac surgery. Neuraxial analgesia is provided through epidural, spinal, and paravertebral routes. Though they are being replaced by peripheral fascial plane blocks, epidural and spinal analgesia are still being used in some centers. In this article, neuraxial forms of analgesia are focused. We sought to review epidural analgesia and its impact in suppressing hemodynamic stress response, reducing pulmonary complications, and development of chronic pain. The relationship between intraoperative heparinization and potential neuraxial hematoma is discussed. Other neuraxial options such as spinal and paravertebral analgesia and their usefulness, benefits, and limitations are also reviewed.

Effectiveness of Standard Local Anesthetic Bupivacaine and Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Truncal Incisions: A Randomized Clinical Trial

IMPORTANCE

Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hours with standard bupivacaine. However, its effectiveness is unknown in truncal incisions for cardiothoracic or vascular operations.

OBJECTIVE

To compare the effectiveness of single-administration standard bupivacaine vs liposomal bupivacaine in patients undergoing truncal incisions.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled patients undergoing sternotomy, thoracotomy, minithoracotomy, and laparotomy from a single cardiovascular surgery department in an academic medical center between November 2012 and June 2018. The study was powered to detect a Cohen effect size of 0.35 with a power of greater than 80%. Data analysis was performed from July to December 2018.

INTERVENTION

Patients were randomized to standard bupivacaine or liposomal bupivacaine.

MAIN OUTCOMES AND MEASURES

Pain was assessed over 3 postoperative days by the Numeric Rating Scale (NRS). Adjunctive opioids were converted to morphine equivalents units (MEU). NRS scores were compared using Wilcoxon rank-sum (3-day area under the curve) and 2-way nonparametric mixed models (daily scale score) to assess time-by-group interaction. Secondary outcomes included cumulative opioid consumption.

RESULTS

A total of 280 patients were analyzed, with 140 in each group (single-administration standard bupivacaine vs liposomal bupivacaine). Mean (SD) age was 60.2 (14.4) years, and 101 of 280 patients (36%) were women. Irrespective of treatment assignment, pain decreased by a mean of approximately 1 point per day over 3 days (β = -0.87; SE = 0.11; mixed model regression P < .001). Incision type was associated with pain with patients undergoing thoracotomy (including minithoracotomy) reporting highest median (interquartile range [IQR]) pain scores on postoperative days 1 (liposomal vs standard bupivacaine, 6 [4-8] vs 5 [3-7]; P = .049, Wilcoxon rank-sum) and 2 (liposomal vs standard bupivacaine, 5 [4-7] vs 4 [2-6]; P = .003, Wilcoxon rank-sum) but not day 3 (liposomal vs standard bupivacaine, 3 [2-6] vs 3 [1-5]; P = .10, Wilcoxon rank-sum), irrespective of treatment group. Median (IQR) 3-day cumulative NRS was 12.0 (8.0-16.5) for bupivacaine and 13.5 (9.0-17.0) for liposomal bupivacaine (P = .15, Wilcoxon rank-sum) Furthermore, use of opioids was greater following liposomal bupivacaine compared with standard bupivacaine (median [IQR], 41.5 [21.3-73.8] MEU vs 33.0 [17.8-62.5] MEU; P = .03, Wilcoxon rank-sum). On multivariable analysis, no interaction by incision type was observed for mean pain scores or opioid use.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial involving truncal incisions for cardiovascular procedures, liposomal bupivacaine did not provide improved pain control and did not reduce adjunctive opioid use compared with conventional bupivacaine formulation over 3 postoperative days.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02111746.

Factors associated with home opioid use after thoracic surgery

OBJECTIVE

Enhanced recovery after surgery (ERAS) with a pre-emptive pain management program has been shown to decrease opioid prescriptions after thoracic surgery. We sought to determine which patient or procedural factors were associated with the need for prescription opioid medications after thoracic surgical procedures.

METHODS

We performed a retrospective analysis of a postoperative pain survey at the time of follow-up in combination with procedural and patient characteristic data. We then performed univariate and multivariate logistic regression to determine factors associated with prescription opioids use.

RESULTS

Two hundred twenty-eight patients completed questionnaires at a median of 37 days after surgery. Most patients received minimally invasive surgery (n = 213, 93%) with the 2 most common types of operations being foregut (n = 92, 40%) and pulmonary resection (n = 80, 35%). Thirty-nine percent of patients (n = 89) were taking chronic pain medications preoperatively, with 15% on chronic opioids medication (n = 33). After surgery, 166 patients (72%) did not take opioids at home. Multivariate analysis showed any chronic opioid medications before surgery (odds ratio, 28.8; 95% confidence interval, 9.13-90.8, P < .001) were associated with opioid use postoperatively. In contrast, increase in age was associated with a decrease in opioid use (odds ratio, 0.96; 95% confidence interval, 0.93-0.99, P = .01).

CONCLUSIONS

ERAS with pre-emptive pain management was associated with patients avoiding opioid prescriptions during recovery. The patient factor of preoperative opioid pain medication(s) and younger age is a significant factor for the patient needing opioids at home after surgery instead of procedural factors. Patient characteristics should be considered when tailoring the patient's pain management after thoracic surgical procedures.

Barriers and Facilitators to the Prevention of Chronic Pain in the Subacute Phase After Cardiac Surgery

BACKGROUND

Although a transitional approach promoting continuity of care is warranted to prevent chronic post-surgical pain (CPSP) and opioid misuse, there is limited research examining interventions targeting the subacute phase after cardiac surgery. Contextual multi-level factors may explain this scarcity.

AIMS

The purpose of this study was to explore the potential implementation of a nursing intervention to prevent CPSP in the subacute phase by describing nurses' viewpoints of current barriers and facilitators.

DESIGN

A descriptive qualitative study was conducted using secondary data analysis.

SETTINGS

A Web-based survey was used along with in-person interviews.

PARTICIPANTS

75 perioperative nurses.

METHODS

Qualitative data from individual interviews (n=10) and open-ended responses to a survey (n=65) regarding the intervention's acceptability were used. Content analysis was conducted using a deductive approach.

RESULTS

The introduction of nurses from various clinical settings to a new intervention allowed reflection on current practice and represented a shift toward a preventive approach. The main barrier expressed was the lack of communication and continuity of care between clinical settings. Several policy implications were outlined such as increasing the involvement of rehabilitation programs and strengthening collaboration between pain specialists and primary care providers.

CONCLUSIONS

Based on perceptions of nurses involved at different stages of the continuum, the findings provide a preliminary picture of clinical challenges and potential avenues for the prevention of CPSP in the subacute phase after cardiac surgery. An expanded pain management nursing role in primary care would allow earlier interventions and contribute to the prevention of CPSP for a tremendous number of patients undergoing surgeries.

Music intervention to relieve anxiety and pain in adults undergoing cardiac surgery: a systematic review and meta-analysis

Objectives

Previous studies have reported beneficial effects of perioperative music on patients’ anxiety and pain. We performed a systematic review and meta-analysis of randomised controlled trials investigating music interventions in cardiac surgery.

Methods

Five electronic databases were systematically searched. Primary outcomes were patients’ postoperative anxiety and pain. Secondary outcomes were hospital length of stay, opioid use, vital parameters and time on mechanical ventilation. PRISMA guidelines were followed and PROSPERO database registration was completed (CRD42020149733). A meta-analysis was performed using random effects models and pooled standardised mean differences (SMD) with 95% confidence intervals were calculated.

Results

Twenty studies were included for qualitative analysis (1169 patients) and 16 (987 patients) for meta-analysis. The first postoperative music session was associated with significantly reduced postoperative anxiety (SMD = –0.50 (95% CI –0.67 to –0.32), p<0.01) and pain (SMD = –0.51 (95% CI –0.84 to –0.19), p<0.01). This is equal to a reduction of 4.00 points (95% CI 2.56 to 5.36) and 1.05 points (95% CI 0.67 to 1.41) on the State-Trait Anxiety Inventory and Visual Analogue Scale (VAS)/Numeric Rating Scale (NRS), respectively, for anxiety, and 1.26 points (95% CI 0.47 to 2.07) on the VAS/NRS for pain. Multiple days of music intervention reduced anxiety until 8 days postoperatively (SMD = –0.39 (95% CI –0.64 to –0.15), p<0.01).

Conclusions

Offering recorded music is associated with a significant reduction in postoperative anxiety and pain in cardiac surgery. Unlike pharmacological interventions, music is without side effects so is promising in this population.

Chronic post-operative opioid use after open cardiac surgery: A Danish population-based cohort study

BACKGROUND

Knowledge of chronic opioid use after cardiac surgery is sparse. We therefore aimed to describe the proportion of new chronic post-operative opioid use after open cardiac surgery.

METHODS

We used prospectively registered data from a national prescription registry and a clinical registry of 29 815 first-time cardiac surgeries from three Danish university hospitals. Data collection spanned from 2003 to 2016. The main outcome was chronic post-operative opioid use, defined as at least one opioid dispensing in the fourth post-operative quarter. Data were assessed for patient-level predictors of chronic post-operative opioid use, including pre-operative opioid use, opioid use at discharge, comorbidities, and procedural related variables.

RESULTS

The overall proportion of post-operative opioid use was 10.6% (95% CI: 10.2-10.9). The proportion of new chronic post-operative opioid use was 5.7% (95% CI: 5.5-6.0) among pre-operative opioid naïve patients. The corresponding proportions among patients, who pre-operatively used low or high dose opioid (1-500 mg or > 500 mg cumulative morphine equivalent opioid), were 68.3% (95% CI: 66.1-70.4) and 76.3% (95% CI: 74.0-78.5) respectively. Risk factors associated with new chronic post-operative opioid use included: female gender, underweight and obesity, pre-operative comorbidities, acute surgery, ICU-time > 1 day, and post-operative complications. Strongest predictor of chronic post-operative opioid use was post-discharge use of opioid within one month after surgery (odds ratio 3.3, 95% CI: 2.8-4.0).

CONCLUSION

New chronic post-operative opioid use after open cardiac surgery is common. Focus on post-discharge opioid use may help clinicians to reduce rates of new chronic opioid users.

Impact of opioid use disorders on outcomes and readmission following cardiac operations

OBJECTIVE

While opioid use disorder (OUD) has been previously associated with increased morbidity and resource use in cardiac operations, its impact on readmissions is understudied.

METHODS

Patients undergoing coronary artery bypass grafting and valve repair or replacement, excluding infective endocarditis, were identified in the 2010-16 Nationwide Readmissions Database. Using International Classification of Diseases 9/10, we tabulated OUD and other characteristics. Multivariable regression was used to adjust for differences.

RESULTS

Of an estimated 1 978 276 patients who had cardiac surgery, 5707 (0.3%) had OUD. During the study period, the prevalence of OUD increased threefold (0.15% in 2010 vs 0.53% in 2016, parametric trend<0.001). Patients with OUD were more likely to be younger (54.0 vs 66.0 years, p<0.001), insured by Medicaid (28.2 vs 6.2%, p<0.001) and of the lowest income quartile (33.6 vs 27.1%, p<0.001). After multivariable adjustment, OUD was associated with decreased mortality (1.5 vs 2.7%, p=0.001). Although these patients had similar rates of overall complications (36.1 vs 35.1%, p=0.363), they had increased thromboembolic (1.3 vs 0.8%, p<0.001) and infectious (4.1 vs 2.8%, p<0.001) events, as well as readmission at 30 days (19.0 vs 13.2%, p<0.001). While patients with OUD had similar hospitalisation costs ($50 766 vs $50 759, p=0.994), they did have longer hospitalisations (11.4 vs 10.3 days, p<0.001).

CONCLUSION

The prevalence of OUD among cardiac surgical patients has steeply increased over the past decade. Although the presence of OUD was not associated with excess mortality at index hospitalisation, it was predictive of 30-day readmission. Increased attention to predischarge interventions and care coordination may improve outcomes in this population.

Development of Persistent Opioid Use After Cardiac Surgery

Importance

The overuse of opioids for acute pain management has led to an epidemic of persistent opioid use.

Objective

To determine the proportion of opioid-naive patients who develop persistent opioid use after cardiac surgery and investigate the association between the initial amount of opioids prescribed at discharge and the likelihood of developing new persistent opioid use.

Design, Setting, and Participants

This retrospective cohort study used data from a national administrative claims database from January 1, 2004, to December 31, 2016 and included 35 817 patients who underwent coronary artery bypass grafting (CABG) (25 673 [71.7%]) and heart valve (10 144 [28.3%]) procedures. All patients were opioid-naive within 180 days before the index procedure and filled an opioid prescription within 14 days after surgery.

Exposures

Opioid medications after cardiac surgery.

Main Outcomes and Measures

The proportion of opioid-naive patients who developed new persistent opioid use within 90 to 180 days after surgery was determined. Oral morphine equivalents (OMEs) were calculated for the first opioid prescription filled after discharge. A multivariable logistic regression with cubic splines was used to analyze the association among the OMEs at discharge and likelihood of developing persistent opioid use.

Results

Of the 25 673 patients who underwent CABG, the mean (SD) age for those without (n = 23 064) vs with (n = 2609) persistent opioid use was 62.9 (9.8) years vs 61.6 (9.7) years, respectively, and the number who were men were 18 758 (81.3%) vs 1998 (76.6%). Of the 10 144 patients who underwent heart valve surgery, the mean (SD) age for those without (n = 9343) vs with (n = 821) persistent opioid use was 63.2 (12.4) years vs 61.2 (12.5) years, respectively, and the number who were men were 6378 (68.3%) vs 511 (62.2%). Persistent opioid use is a substantial concern after cardiac surgery and occurred in 2609 patients undergoing CABG (10.2%) and 821 valve surgery patients (8.1%; P = .001). The likelihood for developing persistent opioid use was decreased among heart valve surgery recipients (odds ratio [OR], 0.78; P < .001) and increased for patients who were women; younger; with preoperative congestive heart failure, chronic lung disease, diabetes, kidney failure, chronic pain, and alcoholism; and those taking preoperative benzodiazepines and muscle relaxants (women: OR, 1.15 [95% CI, 1.03-1.26]; younger age: OR, 1.02 [95% CI, 1.01-1.02]; congestive heart failure: OR, 1.17 [95% CI, 1.06-1.30]; chronic lung disease: OR, 1.32 [95% CI, 1.19-1.45]; diabetes: OR, 1.27 [95% CI, 1.15-1.40]; kidney failure: OR, 1.17 [95% CI, 1.00-1.37]; chronic pain: OR, 2.71 [95% CI, 2.10-3.56]; alcoholism: OR, 1.56 [95% CI, 1.23-2.00]; benzodiazepines: OR, 1.71 [95% CI, 1.52-1.91]; muscle relaxants: OR, 1.74 [95% CI, 1.51-2.02]; all P < .001). Furthermore, we found that when patients were prescribed more than approximately 300 mg of OMEs at discharge, they had a significantly increased risk of new persistent opioid use than with lower opioid prescriptions.

Conclusions and Relevance

Opioids are used extensively after cardiothoracic surgery and nearly 1 of 10 patients will continue to use opioids over 90 days after surgery. Furthermore, higher OMEs prescribed at discharge were significantly associated with developing persistent use. Centers must adopt protocols to increase patient education and limit opioid prescriptions after discharge.

New Persistent Opioid Use After Aortic and Mitral Valve Surgery in Commercially Insured Patients

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.

Predictors of new persistent opioid use after coronary artery bypass grafting

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.