Persistent opioid use among patients who underwent intermediate-to-major elective surgery at a Swiss cantonal hospital: a prospective cohort study

To investigate the extent of persistent opioid use among patients undergoing intermediate-to-major elective surgery at a Swiss cantonal hospital and as a secondary aim to identify factors potentially predictive of persistent opioid use (6 to 12 weeks after surgery).

For this single-centre prospective cohort study, all consecutive patients undergoing elective primary hip arthroplasty, partial or complete prostatectomy, caesarean delivery, spinal surgery, intermediate-to-major visceral surgery or major hand surgery were screened for enrolment from June 2022 to May 2023. We collected basic demographic and medical data, perioperative opioid use (converted to morphine milligram equivalents), postoperative complications, and opioid prescriptions issued by the hospital or other healthcare providers. Telephone interviews about opioid use were conducted with patients 6 weeks after surgery. Only those patients who were still taking opioids at the 6-week interview were contacted 12 weeks after surgery. The primary endpoint was the rate of persistent opioid use 6 or 12 weeks after surgery, and the secondary endpoints were (a) the percentage of patients who received and reported filling prescriptions, and (b) the type and amount of opioids dispensed. With persistent opioid use as the dependent variable, bivariate (predictors: pain or preoperative morphine milligram equivalent) and multivariate logistic regression models were used to assess associations (predictors: age, sex, ASA [American Society of Anesthesiologists] score, preoperative pain).

A total of 855 patients were included in the main analysis. Median age was 62 years (interquartile range [IQR] 45-73), 52% were male and postsurgical complications occurred in 51 patients (6%). Fifty-six patients (7%) were preoperative opioid users. At discharge, 40 patients (5%) received an opioid prescription. Of the 724 patients who completed the 6-week follow-up interview, 30 (4%) had filled an opioid prescription (17 hospital-issued, 9 from an external source and 4 from both). Of the 30 patients (4%) who took opioids, the median length of consumption was 7 days (IQR 3-18). Seventeen patients (2%, 9 preoperative users) were taking opioids after 6 weeks. Seven of these 724 patients (1%, 5 preoperative users) continued use at 12 weeks postoperatively. Bivariate logistic regression analyses showed preoperative pain levels (at rest and during movement) were associated with persistent opioid use (odds ratio [OR] 1.27, 95% confidence interval [CI]: 1.11-1.46, p = 0.001; OR 1.3, 95% CI: 1.12-1.5, p = 0.001, respectively), as were 6-week postoperative pain levels (OR 1.96, 95% CI: 1.61-2.39, p <0.0001; OR 1.82, 95% CI: 1.52-2.18, p <0.0001, respectively). The median preoperative morphine milligram equivalent of persistent opioid users was 60 (IQR 30-180) versus 22.5 (IQR 15-30) in non-persistent users (p = 0.0155). There was a slight positive association between higher preoperative morphine milligram equivalent dosage and persistent postoperative opioid use (OR 1.024, 95% CI: 1.003-1.0456, p = 0.023), with a 2.4% increase in the likelihood of prolonged use per morphine milligram equivalent unit. After controlling for potential confounding factors, multivariate logistic regression analyses indicated associations with higher ASA score (OR 11.8, 95% CI: 2.48-56.51, p = 0.002) and preoperative pain levels (OR 1.23, 95% CI: 1.05-1.43, p = 0.008).

Only a small proportion (1%) of surgical patients continued opioid use 12 weeks after intermediate-to-major elective surgery, with an even much lower proportion (0.3%) having been opioid-naive before surgery. This low rate of prolonged opioid use may be due to the restrictive prescription policy of the centre and local healthcare providers.