Abstract
Background:
There is an opioid epidemic in the United States with a contributing factor being opioids prescribed for post-operative pain following surgery.
Objectives:
Among women who underwent stress incontinence and pelvic organ prolapse surgeries, our primary objective was to determine the proportion of women who filled perioperative opioid prescriptions and to compare factors associated with these opioid prescriptions. We also sought to assess the risk of prolonged opioid use through one year after SUI and POP surgery.
Study Design:
Using a population-based cohort of commercially insured individuals in the 2005–2015 IBM Marketscan® databases, we identified opioid naïve women ≥ 18 years who underwent SUI and/or POP procedures based on CPT codes. We defined the perioperative period as the window beginning 30 days before surgery extending until 7 days after surgery. Any filled opioid prescription in this window was considered a perioperative prescription. For our primary outcome, we report the proportion of opioid naïve women who filled a perioperative opioid prescription and report the median quantity dispensed in the perioperative period. We also assessed demographic and perioperative factors associated with perioperative opioid prescription fills. Prior studies defined prolonged use as the proportion who fill an opioid prescription between 90 – 180 days after surgery. We report this estimate, as well as continuous opioid use, defined as the proportion of women with ongoing monthly opioid prescriptions filled through one-year after SUI and/or POP surgery.
Results:
Among the 217,460 opioid naïve women who underwent urogynecologic surgery, 61,025 (28.1%) had a POP and SUI surgery, 85,575 (39.4%) had SUI without POP surgery and 70,860 (32.6%) had POP without SUI surgery. Overall, 167,354 (77.0%) filled a perioperative opioid prescription, and the median quantity was 30 pills (interquartile range 20, 30). In a multivariate regression model, younger age, POP surgery with or without SUI, abdominal route, hysterectomy and mesh use remained significantly associated with opioid prescriptions filled. Among those with a filled perioperative opioid prescription, the risk of prolonged use, defined as an opioid fill between 90 – 180 days, was 7.5% (95% CI 7.3%,7.6%). However, the risk of prolonged use, defined as continuous use with at least one monthly opioid prescription filled after surgery was significantly lower with the following rates: 1.2% (1.13%, 1.24%), 0.32%(0.29%, 0.35%), 0.06%(0.05%, 0.08%) and 0.04%(0.02%,0.05%) at 60, 90, 180 and 360 days after surgery, respectively.
Conclusions:
Among privately insured, opioid naïve women undergoing SUI and/or POP surgery, 77% of women filled an opioid prescription with a median of 30 opioid pills prescribed. For prolonged use, 7.5% (95% CI 7.3,7.6) filled an opioid within 90–180 days after surgery but the rates of continuously filled opioid prescriptions are significantly lower at 0.06% (95% CI 0.05,0.08) at 180 days and 0.04% (95%CI 0.02,0.05) at 1 year after surgery.
Keywords: Opioids, prolapse, stress incontinence, surgery
Condensation:
Among opioid naïve women undergoing stress incontinence and prolapse surgery, 79% filled an opioid prescription but the rate of prolonged use was low.
Introduction:
There is an opioid epidemic in the United States with 130 Americans dying every day from an opioid overdose1. Overdose deaths involving prescription opioids were 5 times higher in 2017 than in 19991; one contributing factor to this epidemic is prolonged opioid use after surgery. Approximately 3% of previously opioid naïve patients continue to use opioids more than 90 days after major elective surgery2.
Trends in excessive opioid prescribing have been found in the gynecologic literature, with patients being prescribed two to three times the amount of opioids actually used after surgery3, 4. An area that deserves particular attention is women undergoing urogynecologic procedures. Pelvic floor disorders are extremely common with 20% of women undergoing surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP) surgery by age 805. Only a few studies have evaluated the number of opioids prescribed after SUI and POP surgery, and they indicate trends toward overprescribing6, 7. Swenson et al. assessed 50 women and discovered they used one-third of the narcotics prescribed after minimally invasive urogynecologic surgery6. Solouki evaluated 143 patients undergoing urogynecology surgery and found that 82% of patients were prescribed opioids. Of those, 54% reported using less than half of the opioids prescribed7. At this time, population-based data regarding perioperative and long-term opioid use after SUI and POP surgery are extremely limited.
Therefore, the objective of this study was to use a population-based database to evaluate the proportion of women filling perioperative opioid prescriptions and to assess factors associated with these opioid prescriptions following SUI and POP surgery. We also sought to assess the risk of prolonged opioid use through one year after SUI and POP surgery.
Materials and Methods:
This is a retrospective study using a population-based cohort of commercially insured employees, their spouses and dependents in the 2005 to 2015 MarketScan® Commercial Claims and Encounters database and Medicare Supplemental and Coordination of Benefits databases (copyright © 2015 IBM Watson Health. All rights reserved)8, 9. These data include inpatient, outpatient, and pharmaceutical claims which allow for evaluation of dates of service, diagnosis and procedure codes, and all reimbursed outpatient prescription medications. These de-identified data have been found to be both valid and reliable. This study was determined to be exempt from further review by the Institutional Review Board at the University of North Carolina at Chapel Hill as only de-identified data were available.
We included women 18 years and older who underwent SUI and/or POP surgery based on current procedural terminology (CPT) codes (Supplementary Table). Patients were required to have a minimum of 180 days of prior continuous enrollment in Marketscan. In addition, they were required to have a least one prescription fill during this time period, indicating use of a prescription coverage benefit. Patients were followed for up to one-year post-operatively and were censored at occurrence of surgery during follow-up period10, discontinuation of insurance coverage, reaching December 31, 2015 (the last date of available data), or reaching 1-year after surgery.
We assessed prescription claims for drugs including the following opioids: codeine, dextropropoxyphene, hydrocodone, hydromorphone, oxycodone, pentazocine, tramadol, fentanyl, meperidine, morphine, oxymorphone, pethidine, and tapentadol. Of note, the medications are listed according to the active opioid pharmaceutical ingredients. We excluded women with chronic opioid use, which we defined as an opioid prescription filled between 180 to 30 days prior to SUI and/or POP surgery (Figure 1). We were interested in women who were opioid naïve thus women who had ≥ 2 opioid prescriptions filled in the 30-days prior to surgery were also excluded. We acknowledge that some women may receive a prescription at the time of their preoperative visit; thus, we allowed for one opioid prescription within 30-days prior to surgery. The rationale for only allowing one opioid prescription is that two or more opioid prescriptions suggests potential chronic use for nonsurgical related pain.
Figure 1.
Study schematic illustrating requirements for cohort entry.
We defined the perioperative period as the window beginning 30 days before surgery extending until 7 days after surgery. Any filled opioid prescription in this window was considered a perioperative prescription. We used National Drug Code on the prescription claims data to identify the exact opioid prescribed. The data also include information on the number of units dispensed and length in days the prescription was written for (days’ supply). We report the proportion of women who received a perioperative opioid prescription and the median quantity dispensed and days’ supply in the perioperative period by generic opioid ingredient. We also calculated median morphine milligram equivalents (MME).
For our primary outcome, we used absolute standardized mean difference (ASMD) to compare baseline demographics, health comorbidities, and perioperative data including SUI and POP surgery, POP surgery without SUI surgery, SUI surgery without POP surgery, route of surgery, concurrent hysterectomy, and mesh use between those with and without a perioperative opioid prescriptions filled. The absolute SMD has been shown to be a reliable measure in settings with large sample sizes, with differences in ASMD less than 0.10 considered negligible11,12. We also used log-binomial regression adjusting for age, year, region, type of surgery, route of surgery, concurrent hysterectomy and mesh use, and report multivariate adjusted risk ratios and 95% confidence intervals for predictors of perioperative opioid prescriptions.
For our secondary outcome, we used two definitions of prolonged opioid use. First, we defined prolonged opioid use as any prescription filled between 90–180 days after surgery, not requiring any fills in prior months (no continuous use requirement) as this has been the definition commonly used in the existing literature13, 14. In this analysis, we evaluated women who had at least 180 days of follow-up enrollment in the data source. This definition of any opioid fill allows for comparisons with prior research in this area13, 15 In addition, we examined the proportion of women who filled at least one prescription in continuous monthly intervals. Among women with complete follow-up at each time point, we reported the proportion with continuous monthly fills through one-year following SUI and/or POP surgery.
Results:
From 2005–2015, 217,460 opioid naïve women underwent SUI and/or POP surgery. Of those 61,025 (28.1%) underwent POP and SUI surgery, 85,575 (39.4%) underwent SUI surgery without POP surgery, and 70,860 (32.6%) had POP without SUI surgery. For our primary outcome, 167,354 (77.0%) of opioid naïve patients filled a perioperative opioid prescription, while 50,106 (23.0%) did not (Table 1).
Table 1:
Demographics associated with perioperative opioid prescriptions filled
| Characteristic | Perioperative Opioids N=167,354 (77.0%) | No Perioperative Opioids N=50,106 (23.0%) | ASMD |
|---|---|---|---|
| Age at Index Procedure, mean(SD) | 53.0(11.75) | 58.1(13.63) | 0.40 |
| Age Category | |||
| 18–34 | 7,640 (4.4%) | 1,882 (3.6%) | 0.04 |
| 35–44 | 35,448 (20.6%) | 6,610 (12.8%) | 0.21 |
| 45–54 | 55,231 (32.0%) | 12,773 (24.7%) | 0.16 |
| 55–64 | 48,340 (28.0%) | 14,802 (28.6%) | 0.01 |
| 65+ | 25,700 (14.9%) | 15,654 (30.3%) | 0.37 |
| Route | |||
| Abdominal | 14,545 (8.7%) | 3,184 (6.4%) | 0.09 |
| Laparoscopic | 12,006 (7.2%) | 2,457 (4.9%) | 0.10 |
| Vaginal | 140,803 (84.1%) | 44,465 (88.7%) | 0.14 |
| Mesh | |||
| No Mesh | 44,440 (26.6%) | 18,799 (37.5%) | 0.24 |
| Abdominal | 7,877 (4.7%) | 1,764 (3.5%) | 0.06 |
| Laparoscopic | 10,927 (6.5%) | 2,258 (4.5%) | 0.09 |
| Vaginal | 104,110 (62.2%) | 27,285 (54.5%) | 0.16 |
| Concurrent Hysterectomy | 61,976 (37.0%) | 12,544 (25.0%) | 0.26 |
| Type of Surgery | |||
| SUI w/out POP | 65,067 (38.9%) | 20,508 (40.9%) | 0.04 |
| POP w/out SUI | 53,297 (31.8%) | 17,563 (35.1%) | 0.07 |
| SUI and POP | 48,990 (29.3%) | 12,035 (24.0%) | 0.12 |
| Region | |||
| Midwest | 45,050 (26.9%) | 14,646 (29.2%) | 0.05 |
| Northeast | 15,327 (9.2%) | 7,936 (15.8%) | 0.20 |
| South | 76,189 (45.5%) | 18,996 (37.9%) | 0.16 |
| West | 29,071 (17.4%) | 8,099 (16.2%) | 0.03 |
| Unknown | 1,717 (1.0%) | 429 (0.9%) | 0.02 |
| Year | |||
| 2005 | 13,247 (7.9%) | 4,742 (9.5%) | 0.06 |
| 2006 | 12,673 (7.6%) | 4,186 (8.4%) | 0.03 |
| 2007 | 13,520 (8.1%) | 4,222 (8.4%) | 0.01 |
| 2008 | 17,238 (10.3%) | 5,296 (10.6%) | 0.01 |
| 2009 | 20,009 (12.0%) | 5,801 (11.6%) | 0.01 |
| 2010 | 19,348 (11.6%) | 5,467 (10.9%) | 0.02 |
| 2011 | 20,326 (12.1%) | 6,004 (12.0%) | 0.01 |
| 2012 | 17,676 (10.6%) | 5,301 (10.6%) | 0.00 |
| 2013 | 13,918 (8.3%) | 3,906 (7.8%) | 0.02 |
| 2014 | 12,623 (7.5%) | 3,492 (7.0%) | 0.02 |
| 2015 | 6,776 (4.0%) | 1,689 (3.4%) | 0.04 |
| Charlson Comorbidity | 0.2(0.68) | 0.3(0.86) | 0.11 |
| Index, mean(SD) | |||
| Surgical Details | |||
| Inpatient | 52,462 (31.3%) | 15,654 (31.2%) | 0.00 |
| Length of Service, mean(SD) | 0.3(1.91) | 0.3(2.47) | 0.01 |
| *Baseline Non-Opioid Analgesic | 23,398 (14.0%) | 6,416 (12.8%) | 0.04 |
ASMD= absolute standardized mean difference
ASMDs below 0.10 are considered negligible
Classified by redbook therapeutic class=59. Analgesics/Antipyretics, Nonsteroidal anti-inflammatory medications
Patients who filled an opioid prescription were more likely to be younger (53±11.8 filled vs 58±13.6 not filled, ASMD 0.40). The most common route of surgery was vaginal, and this was associated with less opioid prescriptions filled (84.1% filled v 88.7% not filled, ASMD 0.14). Women who underwent concurrent hysterectomy were more likely to fill an opioid at the time of their surgery (37.9% filled v 25.0% not filled, ASMD 0.26). Not having mesh placed at the time of SUI and/or POP surgery was associated with less opioid prescriptions filled (26.6% filled v 37.5% not filled, ASMD 0.24). Those who had both SUI and POP were associated with more opioid prescription filled (29.3 filled v 24.0% not filled, ASMD 0.12). Those with who willed an opioid prescription were more likely to reside in the South (45.5% filled vs 37.9% not filled, ASMD 0.16), and less likely to reside in the Northeast (9.2% filled vs 15.8 not filled, ASMD 0.20%) when compared to those that did not fill an opioid prescription. Healthier women, based on Charlson Comorbidity Index scores, were also more likely to have an opioid prescription filled (0.2±0.68 filled vs 0.3±0.86 not filled, ASMD 0.11). In a multivariate model that controlled for age, year, region, route of surgery, type of surgery and mesh use, younger age, Northeast region, POP surgery with or without SUI, abdominal route, hysterectomy and mesh use remained significantly associated with opioid prescriptions filled (Table 2)
Table 2:
Multivariate Regression for associations of perioperative opioid prescription fill
| Predictors | Adjusted Risk Ratio | 95% CI | |
|---|---|---|---|
| Age Group | |||
| 18–34 | 1.02 | 1.01 | 1.03 |
| 35–44 | 1.03 | 1.02 | 1.03 |
| 45–54 (Referent) | 1.00 | 1.00 | 1.00 |
| 55–64 | 0.95 | 0.95 | 0.96 |
| 65+ | 0.79 | 0.79 | 0.80 |
| Year | |||
| 2005 | 0.98 | 0.97 | 0.99 |
| 2006 | 0.99 | 0.98 | 1.00 |
| 2007 | 0.99 | 0.98 | 1.00 |
| 2008 | 0.99 | 0.99 | 1.00 |
| 2009 | 1.00 | 0.99 | 1.01 |
| 2010 | 1.01 | 1.00 | 1.01 |
| 2011 (Referent) | 1.00 | 1.00 | 1.00 |
| 2012 | 1.00 | 0.99 | 1.01 |
| 2013 | 1.02 | 1.01 | 1.03 |
| 2014 | 1.03 | 1.02 | 1.04 |
| 2015 | 1.04 | 1.03 | 1.05 |
| Region | |||
| Midwest | 1.14 | 1.13 | 1.15 |
| Northeast (Referent) | 1.00 | 1.00 | 1.00 |
| South | 1.17 | 1.16 | 1.18 |
| West | 1.16 | 1.15 | 1.17 |
| Unknown | 1.18 | 1.15 | 1.20 |
| Surgery Type | |||
| SUI without POP (Referent) | 1.00 | 1.00 | 1.00 |
| POP without SUI | 1.04 | 1.03 | 1.05 |
| SUI and POP | 1.03 | 1.03 | 1.04 |
| Route | |||
| Abdominal | 1.03 | 1.03 | 1.04 |
| Laparoscopic | 1.00 | 0.99 | 1.00 |
| Vaginal (Referent) | 1.00 | 1.00 | 1.00 |
| Concurrent Hysterectomy | |||
| Yes | 1.08 | 1.08 | 1.09 |
| No (Referent) | 1.00 | 1.00 | 1.00 |
| Mesh | |||
| Yes | 1.12 | 1.11 | 1.12 |
| No (Referent) | 1.00 | 1.00 | 1.00 |
For perioperative opioids associated with SUI and/or POP surgery, a median quantity of 30 pills were prescribed (IQR 20,30) with a median days’ supply of 4 days (IQR 3,5) and median dosage in MME of 200 (IQR 150,270) (Table 3). When evaluating the results by year, day’s supply, quantity dispense and MME appear relatively stable over time. Hydrocodone was the most common opioid prescribed in the perioperative period (45.6%), followed by oxycodone (34.9%) and dextropropoxyphene (9.0%).
Table 3:
Days and quantities of dispensed opioids
| Year | Median (IQR) | ||
|---|---|---|---|
| Days’ Supply | Quantity Dispensed | MME | |
| 2005 | 4 (3,5) | 30 (20,30) | 200 (150,270) |
| 2006 | 4 (3,5) | 30 (20,30) | 200 (150,270) |
| 2007 | 4 (3,5) | 30 (20,30) | 216 (150,300) |
| 2008 | 4 (3,5) | 30 (20,30) | 200 (150,270) |
| 2009 | 4 (3,5) | 30 (20,30) | 200 (150,270) |
| 2010 | 4 (3,5) | 30 (20,30) | 200 (150,270) |
| 2011 | 4 (3,5) | 30 (20,30) | 188 (150,270) |
| 2012 | 4 (3,5) | 30 (20,30) | 188 (150,270) |
| 2013 | 5 (3,5) | 30 (24,40) | 225 (180,300) |
| 2014 | 5 (3,5) | 30 (24,40) | 225 (150,300) |
| 2015 | 5 (3,6) | 30 (24,40) | 225 (162,300) |
| Overall | 4 (3,5) | 30 (20,30) | 200 (150,270) |
For our secondary outcome of prolonged use, our first definition included patients with any prescription filled between 90–180 days. Among the 124,667 patients with a perioperative opioid prescription who had at least 180 days of follow-up, 7.5% (95% CI 7.3,7.6) had an opioid prescription 90–180 days post-surgery. The second definition of prolonged opioid use, which was defined as one prescription in continuous monthly intervals during follow-up. Using this definition, the rate of prolonged use for the SUI and/or POP surgery group was much lower at 1.18% (95%CI 1.13,1.24) at 60 days, 0.32% (95%CI 0.29,0.35) at 90 days, 0.06% (95%CI 0.05,0.08) at 180 days and 0.04% (95%CI 0.02,0.05) at 1 year (Table 4).
Table 4:
Rate of continuous and any medication refills post-surgery
| Days Post Surgery | Monthly Refills | |
|---|---|---|
| Continuous Fills % (95%CI) | Any Fills % (95%CI) | |
| 30 | 10.12 (9.97, 10.27) | 9.81 (76.78, 77.14) |
| 60 | 1.18 (1.13, 1.24) | 3.32 (3.23, 3.41) |
| 90 | 0.32 (0.29, 0.35) | 2.97 (2.89, 3.06) |
| 120 | 0.15 (0.13, 0.17) | 2.95 (2.86, 3.04) |
| 150 | 0.09 (0.08, 0.11) | 3.00 (2.91, 3.09) |
| 180 | 0.06 (0.05, 0.08) | 3.07 (2.97, 3.16) |
| 210 | 0.05 (0.04, 0.06) | 3.11 (3.01, 3.21) |
| 240 | 0.05 (0.03, 0.06) | 3.02 (2.92, 3.12) |
| 270 | 0.04 (0.03, 0.06) | 3.00 (2.89, 3.10) |
| 300 | 0.04 (0.03, 0.05) | 3.19 (3.08, 3.30) |
| 330 | 0.04 (0.03, 0.05) | 3.18 (3.07, 3.29) |
| 360 | 0.04 (0.02, 0.05) | 2.98 (2.87, 3.09) |
Comment:
Principal Findings
We found that most women undergoing surgery for SUI and POP surgery had a perioperative opioid prescription filled but the rate of prolonged opioid use was low.
Results
Of women undergoing SUI and POP surgery, 77% filled a perioperative opioid prescription. This is a relatively large percentage especially considering that a sizable number of these prescribed opioids go unused7, 16. Solouki and colleagues found similar results when evaluating 143 patients undergoing urogynecologic surgery, with 82% being prescribed an opioid7. However, this study described an average of 12–17 opioid tablets prescribed, which is lower than our median of 30 tablets prescribed. This difference could be a result of the broad time frame of 2005–2015 and a larger population for our data collection.
Interestingly, although the median number of opioids prescribed was similar over the time period of the study, with 30 pills (IQR 20, 30) in 2005 and 30 pills (IQR 24,40) in 2015. More recently, healthcare institutions have become increasingly aware of opioid over-prescribing habits and have implemented initiatives, such as enhanced recovery after surgery (ERAS) protocols, in an attempt to reduce about the number of opioids prescribed perioperatively17, 18. ERAS protocols are evidence-based interventions designed to standardize perioperative care in order improve recovery after surgery. Implementation of these protocols for pelvic reconstructive surgery have been associated with a decrease in opioid use and other benefits including patient staisfaction18. Initiatives such as these may not have been reflected during the time period of our study. Larger studies looking specifically at hysterectomies have also found rates of opioid prescriptions ranging from 82–84%19, 20. Our previously published study of persistent opioid use after hysterectomy also found a median number of 30 tablets (IQR 25–40) prescribed at the time of surgery20. This further suggests that trends toward over-prescribing are not unique to Urogynecology but span across the entire field.
Although our study centered on perioperative opioid prescriptions filled, prior studies have shown similar findings in regard to risks factors for postoperative pain. We found that concurrent SUI and POP surgery was a risk factor with opioid prescription fill. Previous studies have shown that stress incontinence surgery at the time of prolapse repair to be a risk factor for increased pain21, 22. Vaginal route of surgery was associated with less opioid prescriptions filled. This is consistent with findings from Dr. As-Sanie’s study on opioid prescribing patterns after benign hysterectomy that showed that vaginal hysterectomy was associated with both less opioids prescribed as well as less reported opioid use following vaginal hysterectomy when compared to laparoscopic and abdominal routes3. In contrast to work published by Westermann et al. that concluded that patients reported less pain after robotic sacrocolpopexy when compared to vaginal apical repair using uterosacral ligament suspension23. Studies have shown that mesh placement is also associated with increased pain following pelvic reconstructive surgery24, 25. Thus, it is not surprising that our study showed mesh placement as a risk factor for opioid prescription fill. Our results showing that younger women were more likely to fill their opioid prescriptions is consistent with previous literature noting higher rates of pain in the acute postoperative period following pelvic reconstructive surgery as well as increased risks of chronic pain following hysterectomies for benign conditions22, 26, 27.
Our rate of 7.5% for any opioid filled between 90–180 days is similar to prior research. Brummet et al. used nationwide insurance claims from 2013–2014 to assess new persistent opioid use in adults undergoing both major and minor surgeries13. They found that in women who underwent a hysterectomy and received an opioid prescription, 6% had persistent use 90–180 days after surgery. Buono and colleagues found a higher rate 15.9% receiving an additional postoperative opioid prescription within 90 days after urogynecologic surgery with the most common indication being chronic pain syndrome14.
We believe that using the criteria of any opioid filled between 90–180 days after surgery may not adequately reflect patients with persistent opioid use as a result of their surgery. For example, a postoperative patient may suffer a completely unrelated injury 3–6 months after surgery and receive an opioid prescription. Using the definition of any opioid prescription filled in the 90–180 days after surgery, this opioid prescription would meet the definition for prolonged postsurgical opioid use. Thus, we used a potentially more accurate definition of prolonged use by evaluating continuous monthly fills, thereby capturing ongoing monthly opioid prescription up to one year. Our findings show that continuous monthly fills are quite low with rates of 1.2% at 60 days after surgery and a continued decline to 0.04% at 1 year. Rate of prolonged opioid use varies widely depending on the definition used but we believe that continuous fills may be a more accurate depiction of this issue.
Clinical Implications
This study illustrates that opioids are routinely prescribed after SUI and POP surgery but the risk of prolonged use in this population is low. While this data is reassuring clinicians should strive find ways to reduce the amount opioids prescribed to our patients. Policy makers should continue to support research identifying alternatives to opioids and promote educational tools to the public to combat opioid addiction in this country.
Research Implications
It will be important to continue developing nonopioid multimodal therapies to decrease the rate and number of opioids prescribed to treat postoperative pain in those having pelvic floor surgery. In addition, questionnaires to indicate what patients are less likely to need opioids would help surgeons individualize postoperative pain management hopefully leading to a decrease in prescribed opioids. More recent population-based studies that include institutions with ERAS protocols will also give a more accurate view of the current state of opioid prescribing habits in the urogynecology population.
Strengths and Limitations
The strengths of this study include the evaluation of a large population-based cohort with over 194,000 women. We used an insurance claims database covering patients across the United States undergoing SUI and/or POP surgery. We assessed opioid naïve women and used two definitions of prolonged opioid use allowing for both comparisons to previous studies as well as introducing continuous use data that may provide more precise information regarding prolonged opioid use after surgery.
Limitations include that the results reflect women with private insurance; thus, these results may not be generalizable to those who are underinsured or uninsured. We also cannot determine the exact indication for opioid prescriptions filled but using the definition of continuous monthly fill allows for a better estimate of prolonged opioid use related to surgery. The claims data does not include information on pain severity prior to or following surgery, which may be an important factor related to receipt of a perioperative opioid prescription and risk of prolonged opioid use. This study was unable to account for opioids purchased directly without insurance or obtained from other sources, therefore, there is a possibility that the rate of prolonged opioid use after surgery is higher.
Conclusions
In conclusion, among opioid naïve women undergoing SUI and/or POP surgery 79% of women filled an opioid prescription with a median of 30 opioid pills prescribed. While it is clear that opioid prescribing has become a routine part of perioperative care, the risk of prolonged use after surgery is reassuring with continuous monthly opioid fills being extremely low through one year after surgery.
Supplementary Material
AJOG at a Glance.
A. Why was this study conducted?
The study was conducted to evaluate the proportion of women filling perioperative opioid prescriptions and to compare factors associated with women who filled perioperative opioid prescriptions to those that did not following pelvic reconstructive surgery
B. What are the key findings?
Among opioid naïve women undergoing urogynecologic surgery, 77% of women filled an opioid prescription, but the risk of prolonged use was low.
C. What does this study add to what is already know?
This study evaluates opioid prescriptions filled after urogynecologic surgery using a large population-based cohort and provides data on prolonged opioid use using two definitions.
Disclosure statement:
Jessica C. Young is supported by the National Institute on Drug Abuse, through Grant Award Number R36 DA04588501.
Dr. Jonsson Funk is supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR002489. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
The database infrastructure used for this project was funded by the Pharmacoepidemiology Gillings Innovation Lab (PEGIL) for the Population-Based Evaluation of Drug Benefits and Harms in Older US Adults (GIL200811.0010), the Center for Pharmacoepidemiology, Department of Epidemiology, UNC Gillings School of Global Public Health, the CER Strategic Initiative of UNC’s Clinical Translational Science Award (UL1TR002489), the Cecil G. Sheps Center for Health Services Research, UNC, and the UNC School of Medicine.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Paper Presentation Information: Young J, Jonsson Funk M, Willis-Gray M, Pate V, Wu JM. Risk of prolonged opioid use after surgery for stress incontinence and pelvic organ prolapse. American Urogynecologic Society / International Urogynecological Association joint scientific meeting, Sept 24–28, 2019, Nashville, TN. [Abstract] Female Pelvic Med Reconstr Surg. 2019 Sept/Oct; 25(5) Suppl1:S55. Presented as an oral presentation.
References
- 1.Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2017; Available from: http://wonder.cdc.gov. [Google Scholar]
- 2.Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014; 348:g1251. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.As-Sanie S, Till SR, Mowers EL, Lim CS, Skinner BD, Fritsch L, et al. Opioid Prescribing Patterns, Patient Use, and Postoperative Pain After Hysterectomy for Benign Indications. Obstet Gynecol. 2017; 130:1261–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Patanwala I, Ouyang C, Fisk M, Lamvu G. Opioid Prescription Usage after Benign Gynecologic Surgery: A Prospective Cohort Study. J Minim Invasive Gynecol. 2019. [DOI] [PubMed] [Google Scholar]
- 5.Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014; 123:1201–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Swenson CW, Kelley AS, Fenner DE, Berger MB. Outpatient Narcotic Use After Minimally Invasive Urogynecologic Surgery. Female Pelvic Med Reconstr Surg. 2016; 22:377–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Solouki S, Plummer M, Agalliu I, Abraham N. Opioid prescribing practices and medication use following urogynecological surgery. Neurourol Urodyn. 2019; 38:363–8. [DOI] [PubMed] [Google Scholar]
- 8.Truven Health Analytics MarketScan® Commercial Claims and Encounters Database. Source: MarketScan® is a registered trademarks of Truven Health Analytics formerlyThomson Reuters (Healthcare) Inc Available at: http://truvenhealth.com/markets/life-sciences/products/data-tools. Retrieved on October 12, 2016.
- 9.MarketScan Data in Action: Epidemiology Studies. White paper, 2015. Available at: http://truvenhealth.com/markets/life-sciences/products/data-tools/marketscan-databases. Retrieved on October 12, 2016.
- 10.Osmolality Urine [database on the Internet]2009–2010. Available from: http://wwwn.cdc.gov/Nchs/Nhanes/2009-2010/UCOSMO_F.htm
- 11.Software SF. Healthcare Cost and Utilization Project (HCUP). June 2018; Available from: www.hcup-us.ahrq.gov/toolssoftware/surgflags/surgeryflags.jsp
- 12.Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Statistics in medicine. 2009; 28:3083–107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017; 152:e170504. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Buono K, Brueseke T, Wu J, Whitcomb E. Evaluation of Opioid Prescriptions After Urogynecologic Surgery Within a Large Health Care Organization: How Much Are We Prescribing? Female Pelvic Med Reconstr Surg. 2019; 25:125–9. [DOI] [PubMed] [Google Scholar]
- 15.Johnson SP, Chung KC, Zhong L, Shauver MJ, Engelsbe MJ, Brummett C, et al. Risk of Prolonged Opioid Use Among Opioid-Naive Patients Following Common Hand Surgery Procedures. The Journal of hand surgery. 2016. [DOI] [PubMed] [Google Scholar]
- 16.Hota LS, Warda HA, Haviland MJ, Searle FM, Hacker MR. Opioid use following gynecologic and pelvic reconstructive surgery. Int Urogynecol J. 2018; 29:1441–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Modesitt SC, Sarosiek BM, Trowbridge ER, Redick DL, Shah PM, Thiele RH, et al. Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization. Obstet Gynecol. 2016; 128:457–66. [DOI] [PubMed] [Google Scholar]
- 18.Trowbridge ER, Evans SL, Sarosiek BM, Modesitt SC, Redick DL, Tiouririne M, et al. Enhanced recovery program for minimally invasive and vaginal urogynecologic surgery. Int Urogynecol J. 2019; 30:313–21. [DOI] [PubMed] [Google Scholar]
- 19.Thompson JC, Komesu YM, Qeadan F, Jeppson PC, Cichowski SB, Rogers RG, et al. Trends in patient procurement of postoperative opioids and route of hysterectomy in the United States from 2004 through 2014. Am J Obstet Gynecol. 2018; 219:484 e1–e11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Young JC, Wu JM, Willis-Gray M, Pate V, Jonsson Funk M. Persistent Opioid Use After Hysterectomy in the United States, 2005–2015. Obstet Gynecol. 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Celik F, Pektas MK, Kose M, Arioz DT, Yesildager E, Yilmazer M. Two-Year Follow-Up Results of Transobturator Tape Procedure with and without Concomitant Vaginal Surgery. Urol Int. 2018; 100:402–8. [DOI] [PubMed] [Google Scholar]
- 22.Shatkin-Margolis A, Crisp CC, Morrison C, Pauls RN. Predicting Pain Levels Following Vaginal Reconstructive Surgery: Who Is at Highest Risk? Female Pelvic Med Reconstr Surg. 2018; 24:172–5. [DOI] [PubMed] [Google Scholar]
- 23.Westermann LB, Crisp CC, Mazloomdoost D, Kleeman SD, Pauls RN. Comparative Perioperative Pain and Recovery in Women Undergoing Vaginal Reconstruction Versus Robotic Sacrocolpopexy. Female Pelvic Med Reconstr Surg. 2017; 23:95–100. [DOI] [PubMed] [Google Scholar]
- 24.Geller EJ, Babb E, Nackley AG, Zolnoun D. Incidence and Risk Factors for Pelvic Pain After Mesh Implant Surgery for the Treatment of Pelvic Floor Disorders. J Minim Invasive Gynecol. 2017; 24:67–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Abbott S, Unger CA, Evans JM, Jallad K, Mishra K, Karram MM, et al. Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study. Am J Obstet Gynecol. 2014; 210:163 e1–8. [DOI] [PubMed] [Google Scholar]
- 26.Willis-Gray MG, Husk KE, Brueseke TJ, Wu JM, Dieter AA. Predictors of Opioid Administration in the Acute Postoperative Period. Female Pelvic Med Reconstr Surg. 2018. [DOI] [PubMed] [Google Scholar]
- 27.Pinto PR, McIntyre T, Nogueira-Silva C, Almeida A, Araujo-Soares V. Risk factors for persistent postsurgical pain in women undergoing hysterectomy due to benign causes: a prospective predictive study. J Pain. 2012; 13:1045–57. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.