Short-term Prescriptions for Analgesics can Lead to Long-term Use

Abstract & Commentary

By Rahul Gupta, MD, MPH, FACP, Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV. Dr. Gupta reports no financial relationships relevant to this field of study.

Synopsis: Elderly patients are often prescribed analgesics after ambulatory and short-stay surgery which may lead to their long-term use.

Source: Alam A, et al. Long-term analgesic use after low-risk surgery: A retrospective cohort study. Arch Intern Med 2012; 172:425-430.

Pain control following surgery is a major priority for both the patient and the physician. It is a common practice to prescribe analgesics to patients undergoing ambulatory and short-stay surgery. From the prescriber's point of view, it is important to keep the patient pain free during the postoperative period. This helps reduce suffering and maintains the patient in a comfortable state during the recovery period. The most common analgesics prescribed in such situations are opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). These medications must be used judiciously since the short- and long-term use of both opioids and NSAIDS is associated with significant adverse effects. In patients undergoing surgery, overprescription of opioids is common and retained surplus medication presents a readily available source of opioid diversion. In one such study, it was reported that more than 40% of the narcotic medication prescribed after ambulatory surgery or hospital discharge remained unused and nearly two-thirds of patients had leftover medication with no disposal instructions for the surplus medication.1 Not only does this present a risk of opioid diversion but the long-term use, especially among the elderly, can lead to physiologic tolerance, addiction, and other drug-related issues.

In their study, Alam et al aimed to determine whether de novo administration of analgesics to elderly patients after short-stay operations was associated with long-term use of these medications. Researchers conducted a retrospective, nested-cohort study among 391,139 patients from Ontario, Canada, who were 66 years of age and older. During the study period, the subjects included those who were discharged alive after low-pain short-stay surgery hospitalizations such as cataract surgery, laparoscopic cholecystectomy, transurethral resection of the prostate, and varicose vein stripping surgery. Exposure was defined as administration of any opioid prescription within 7 days of hospital discharge. Long-term opioid use was defined as an additional claim for any opioid within 60 days of the 1-year anniversary date of the surgery.

Researchers found that opioids were newly prescribed to 27,636 patients (7.1%) within 7 days of being discharged from the hospital. A total of 30,145 patients (7.7%) were prescribed opioids at 1 year from surgery. Furthermore, patients receiving an opioid prescription within 7 days of surgery were 44% more likely to become long-term opioid users within 1 year compared with those who received no such prescription. The most commonly prescribed opioid was codeine followed by oxycodone. In a secondary analysis, among 383,780 NSAID-naïve patients undergoing short-stay surgery, NSAIDs were prescribed to 1169 patients (0.3%) within 7 days of discharge and to 30,080 patients (7.8%) at 1 year from surgery. Patients who began taking NSAIDs within 7 days of surgery were almost four times more likely to become long-term NSAID users compared to patients with no such prescription. The authors concluded that prescription of analgesics immediately after ambulatory surgery occurs frequently in older adults and is associated with their long-term use.

Commentary

While there is both a moral and scientific obligation upon the physician to fully treat pain, the above study illustrates how what is often done to comfort patients in the short term can have longer term consequences. While it is possible that patients undergoing short-stay surgery could have pre-existing untreated pain, it is alarming to see that elderly patients who were prescribed opioids within 7 days of the surgery were much more likely to become long-term opioid users within 1 year when compared to no prescription. Studies have found that the use of opioids among the elderly may be placing them at risk for serious adverse events, including falls, fractures, cardiovascular events, and even death.2 It is important to note that opioid analgesics are not necessarily safer than non-opioid analgesics such as NSAIDS. However, it is equally disturbing to find in the study that many of those NSAID-naïve elderly patients who were initially prescribed NSAIDs after short-stay surgery continued to use these medications 1 year later. In the elderly, NSAIDS may place patients at especially higher risk for gastrointestinal hemorrhage, cardiovascular events, renal damage, falls, and adverse events from polypharmacy.

While many patients will still need to be treated with analgesics postoperatively, it is important to understand that most analgesics, whether opioids or NSAIDS, place elderly patients at higher safety risks. Therefore, prior to prescribing analgesics, physicians may want to ascertain the need for such. Keeping the patient's medical history and various organ functional status in mind, elderly patients should be started on analgesic medications at low doses, actively monitoring for side effects, while avoiding polypharmacy. Providing patient and caregiver education — including efforts to improve patients' understanding of safe medication taking upon discharge and proper disposal — may prevent many elderly patients from unnecessarily seeking out such analgesics in the long-term.

References

1. Bates C, et al. Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption and disposal in urological practice. J Urol 2011;185:551-555.

2. Solomon DH, et al. The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults. Arch Intern Med 2010;170:1979-1986.