Commentary on “Age and postoperative opioid use in women undergoing pelvic organ prolapse surgery”

Despite the ongoing endeavors to limit the issuance of opioid prescriptions, there has been a consistent upward trend in opioid-related fatalities over the past few years and prescription opioids account for more than 20% of all opioid-related fatalities (1). A predominant portion of these fatalities continue to affect individuals between the ages of 25 and 54 years, highlighting the persistent challenge in preventing avoidable losses within this demographic (2). Research within urology has demonstrated a significant increase in the risk of developing persistent opioid use disorder with post-operative opioid prescriptions, across a variety of surgical procedures (3-6). Within gynecology literature, a recent meta-analysis of nearly 400,000 patients demonstrates that the risk of persistent opioid use after benign hysterectomy is approximately 5%—and those at higher risk are of younger age, with a history of smoking or alcohol use, and/or prior chronic pain (7). Specifically within urogynecology, prior research has illustrated an inverse relation between age at time of surgery and post-operative opioid prescriptions, pain intensity, and opioid refill post-discharge (8-11). Cummings et al. further contributed to this body of literature by establishing the same, inverse linear relationship between patients’ age and postoperative opioid use following multi-compartment pelvic organ prolapse (POP) surgery (12).

Cummings et al. used data from the Hysterectomy vs. Uterine Preservation for Pelvic Organ Prolapse Surgery (HUPPS) cohort in Alberta, Canada. They conducted logistic regression analysis to contrast women who received postoperative opioids with those who did not, as well as linear regression analysis to assess the impact of age on opioid dose (12). The study, though lacking post-operative pain scores, found that among the 61.5% of women who received post-operative opioids, mean opioid dose was 26.6±23.3 mg morphine equivalent daily dose (MEDD) and increase in age by each year was associated with a −0.65 mg MEDD mean reduction in opioid dose, with no evidence for a non-linear effect of age. Unfortunately, the authors did not provide data on their adjusted model that included the significance and magnitude of effect of a priori covariates—and only report the modified effect of age on their outcome of interest. In their cohort, a higher proportion of patients who used opioids were more likely to be younger, smoke, report pre-existing pelvic pain, have anxiety or depression, as well as longer operative time, inclusion of hysterectomy, and inclusion of mid-urethral sling. It is possible that these important covariates are of greater significance than age.

With growing recognition for the various biological and psychosocial factors, preoperative counseling regarding immediate and long-term post-operative pain expectations and the risk of persistent post-operative opioid use is imperative. Chiefly, the study from Cummings et al. supports efforts for expectation-setting tailored to patient age. The findings underscore the importance of recognizing that younger patients may particularly benefit from additional strategies and support in managing pain. However, their data neglect to include the significance of other factors that influence postoperative opioid use. In light of this elevated risk, it is imperative for physicians to proactively engage in preoperative patient counseling and implement postoperative pain management protocols that follow Enhanced Recovery After Surgery (ERAS) guidelines while also individualizing pain management needs and being cognizant of each patient’s unique risk factors for persistent opioid use (including, but not limited to, age alone). The implementation of procedure-specific, tiered, multimodal opioid limiting recommendations has been shown to be linked with a sustained reduction in the prescription of opioids (13). Hence, it is crucial to assess each patient individually and customize post-operative treatment plans, rather than uniformly prescribing potent, addictive medications with significant side effects. Addressing the opioid epidemic requires proactive efforts and comprehensive patient and provider education; the recognition, acknowledgment, and appropriate treatment of pain tailored to patient characteristics signifies a positive step in the right direction.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article has undergone external peer review.

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