This poll was based on a recent study of opioid use post cardiac surgery. The analysis was prompted by the continuing assessment of prescribing practices and the current epidemic of opioid overuse.

Brown et al.¹ performed a retrospective insurance-claims analysis of over 35,000 cardiac surgery patients. Patients included for analysis were opioid naïve for >6 months prior to surgery. Overall, 10% of patients demonstrated persistent opioid use 90-180 days post-surgery. Patients at higher risk of late use included women, younger patients, and those with congestive heart failure on admission, chronic obstructive pulmonary disease, diabetes, kidney failure, and prior alcoholism or chronic use of benzodiazepines and muscle relaxers. In addition, a discharge dose of >300 mg oral morphine equivalents was a risk factor for late use.

Limitations to this study include that it is based on private insurance of managed Medicare patients. Such databases are subject to coding errors and may not be representative of all populations and, importantly, may not represent other sources of narcotics.

In an accompanying editorial, Farmer et al.² noted that no attempt to screen patients prior to surgery was included in this study, but rapid screening tests are available that are reported to be easy to administer and potentially worthwhile for assessing addictive risk. An analysis of the benefit of such screening could be a worthwhile future clinical trial. Despite a lack of proven efficacy, screening could be considered on an individual treatment basis.

An interesting idea is whether increased risk of opioid overuse might be an additional consideration in the multiple factors that heart teams consider when assessing recommendations for surgical or interventional treatment of patients with complex multivessel disease.

The poll had a low response rate, but given only a 10% risk, it may be difficult to easily recognize continued opioid use in small patient samples. On the second question, as noted above, there is a greater risk for patients who had coronary artery bypass grafting compared to valve surgery. Awareness of this risk is an important factor in addressing the opioid epidemic.

References

1. Brown CR, Chen Z, Khurshan F, Groeneveld PW, Desai ND. Development of Persistent Opioid Use After Cardiac Surgery. JAMA Cardiol 2020;5:889-96.
2. Farmer SA, Schreiber M, Horvath KA. Slowing the Opioid Epidemic by Controlling a Source: Disabling the Pump. JAMA Cardiol 2020;June 17:[Epub ahead of print].

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Novel Agents, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Coronary Angiography, Analgesics, Opioid, Narcotics, Benzodiazepines, Patient Discharge, Medicare, Risk Factors, Retrospective Studies, Insurance Claim Review, Opioid-Related Disorders, Morphine, Coronary Artery Bypass, Behavior, Addictive

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