By Becky Bach
As an anesthesiologist, Sesh Mudumbai, MD, knows that patients heading home after surgery with an opioid prescription face a variety of risks, including the potential of overdose or addiction. He suspected that patients might be more likely to overdose — either accidentally or intentionally — if they had a more complex surgery, such as heart or spine surgery.
So, working with colleagues including Randall Stafford, MD, PhD, director of Stanford's Program on Prevention Outcomes and Practices, Mudumbai, who is a staff anesthesiologist at the VA Palo Alto Health Care System, dug into the data. The researchers compiled information from nearly all Veterans Health Administration patients — 64,391 people — who had surgery in 2011 and examined their opioid use, as well as any overdoses in the first year following surgery. Nearly all of the patients were prescribed opioids — only 4 percent were not taking opioids 30 days after surgery.
The research appears in Pain Medicine.
It turns out that the type of surgery isn't significantly connected with a higher chance of overdose in the veteran population. Instead, the time period and the type of opioids prescribed were the most significant factors, the researchers found. The overdose rate is highest in the first few months following hospital discharge.
"This is a very important finding that the short-term risks are high right after hospital discharge and should be a concern for physicians and providers," Mudumbai said.
Within the first month, the overdose rate — with a total of 68 overdoses — was almost 11 times higher than it was during the rest of the first year. Mudumbai said they didn't specifically examine why, but he has a few theories.
"Immediately after surgery is a time when patients are in pain, they are also exposed to increasing doses of opioids in an uncontrolled setting where they aren't as closely monitored," he said. "They may also be going back to taking other medications such as sleeping pills that can interact with opioids."
The study's other important finding concerns the risks associated with different types of opioids, which are generally classified as short-acting or long-acting. Current thought is that long-acting opioids are more likely to cause overdoses than short-acting overdoses, Mudumbai told me.
Yet, the study found that the combination of short- and long-acting was the most dangerous for these veterans, who are primarily male and older and are recovering from surgery.
And although the data were collected in 2011, the research is still relevant, Mudumbai said, because in many parts of the U.S. it is still routine practice to give surgery patients a several month prescription of opioids as they leave the hospital. Veterans, who also have higher rates of mental disorders and substance use, are also a particularly vulnerable population that demands attention, he said.
The takeaway from the work is straightforward, Mudumbai told me: "Surgical patients should be given the lowest intensity of opioids possible and should be closely watched after hospital discharge if they are taking high doses of opioids."