Pre-op opioid use linked with worse outcomes after Crohn's disease surgery

Last Updated: 2016-03-03

By Joan Stephenson

NEW YORK (Reuters Health) - Patients with Crohn's disease who take narcotic medications before surgery to treat their condition are significantly more likely than those who do not to have 30-day postoperative complications and a longer hospital stay, a new study has found.

Previous studies had indicated that narcotics are often used to manage chronic pain in patients with inflammatory bowel disease (IBD), and that a significant proportion of patients with Crohn's disease are long-term narcotics users.

The new study's findings suggest that "consideration should be given to surgery before the patient becomes a chronic narcotic user," corresponding author Dr. Luca Stocchi, of the Cleveland Clinic in Ohio, told Reuters Health by email. The thinking, he and his colleagues noted, is that earlier surgery for patients with active Crohn's disease that is unresponsive to medical management has the potential to prevent the initiation of narcotic use in such patients.

Use of opioids among patients with Crohn's disease has been specifically associated with increased infection risk, increased disease activity, depression, anxiety, and decreased quality of life. However, the researchers noted, data on the specific effects of preoperative narcotic use on postoperative outcomes for patients who undergo abdominal surgery for the condition are sparse.

Dr. Stocchi said the researchers decided to study this particular question because of their impression that "we are dealing with an increased rate of chronic narcotic use in the patient population having Crohn's disease, which might reflect the nationwide narcotics epidemic."

The study involved a review of patient clinical profiles from a prospectively maintained Crohn's disease database at the Cleveland Clinic. A total of 1,461 abdominal operations were performed on 1,331 patients (mean age 41.2 at the time of surgery); 267 (18.3%) of the surgeries involved patients who had at least one pharmacy claim for narcotics during the month before the operation.

Preoperative narcotic use was associated with a longer mean hospital stay (11.2 versus 7.7 days, p<0.001) and a greater likelihood of postoperative complications (52.8% versus 40.8%; p<0.001), the researchers reported online February 24 in JAMA Surgery.

Specific complications associated with preoperative narcotic use included surgical site infections, urinary tract infections, ileus, and thromboembolism.

Mortality, though rare (two deaths per 1,194 surgeries in the no-narcotics group versus three per 267 surgeries among patients receiving preoperative narcotics), was significantly increased among the latter (p=0.05).

Multivariable analysis also determined that preoperative narcotic use was an independent risk factor associated with postoperative morbidity (odds ratio 1.36; p=0.04) and prolonged hospital stay (OR, 2.91; p<0.001).

The study "reinforces our belief that chronic use of narcotics as part of a medical treatment plan for Crohn's disease is ill-advised in most cases," Dr. Stocchi said.

"In general, if a patient with Crohn's disease already on medical management develops worsening symptoms, this is an indication that the disease is poorly responsive to medical management, and therefore consideration for surgery is in order," he said.

Despite the study's limitations, such as the single-center setting, retrospective nature of the analysis, and inability to account for inpatient narcotic use during the hospitalization, "the results remain compelling," Dr. Millie D. Long, of the Multidisciplinary Inflammatory Bowel Diseases Center at University of North Carolina at Chapel Hill, told Reuters Health by email.

Dr. Long, who was not involved with the current study, said she agrees with the authors that clinicians who treat IBD "should recognize that outpatient chronic narcotic use can lead to complications, including increased narcotic prescriptions during hospitalizations, infectious risks, and now surgical complications."

Optimizing pain management through means other than narcotics "is of utmost importance for IBD patients," she said. "In many instances, timely medical and surgical management along with centrally acting agents for visceral hypersensitivity can help to prevent the need for chronic narcotics."

The study had no commercial funding and the authors reported no disclosures.

SOURCE: http://bit.ly/1VP0yEm

JAMA Surg 2016