Why Some Patients Continue to Take Opioids Long After Surgery

The current drug addiction epidemic in the United States has been largely blamed on the careless over-prescription of opioid pain relievers.

For example, addiction expert Andrew Kolodny, M.D., wrote in the New York Times that a brilliant marketing campaign resulted in well-intentioned doctors and dentists overprescribing opioids for common conditions. The “sharp rise in prescriptions led to parallel increases in addiction and overdose deaths.” That seems to suggest, if you take opioids long enough, you become addicted to them.

That’s not how addiction journalist Maia Szalavitz views addiction. For her, there is more to it. “Drugs are powerful primarily when the rest of your life is broken,” Szalavitz writes in her book Unbroken Brain. “By itself, nothing is addictive; drugs can only be addictive in the context of set, setting, dose, dosing pattern, and numerous other personal, biological, and cultural variables. Addiction isn’t just taking drugs. It is a pattern of learned behavior.”

A new study looked at patients and their opioid use following surgical procedures. Chad Brummett, M.D., of the University of Michigan Medical School, and colleagues evaluated data for 36,177 surgery patients who had never taken opioids. Roughly 80 percent underwent minor surgery, such as varicose vein removal or a range of minimally invasive operations. The other 20 percent had major surgery, such as a hysterectomy or colectomy.

The researchers found that "new persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders."

“Persistent use was defined conservatively as 90 days or more days after surgery,” says Dr. Brummett. As he explained to me, his team did not establish whether any of the patients in the study had developed an opioid addiction. But the results of the study clearly suggest “the patients were not continuing to take opioids for surgical pain,” says Dr. Brummett. In other words, the surgery itself was not the cause of the continued use.

So, what was the difference? Why were some patients still taking opioids more than 90 days after a hernia operation?

“In this cohort, tobacco use, alcohol and substance abuse disorders, and comorbid conditions increased the risk of new persistent opioid use among opioid-naive patients, regardless of surgical procedure,” we read in the study. “In addition, anxiety, depression, and other preoperative pain disorders (ie, back pain, neck pain, arthritis, and centralized pain conditions) were independently associated with continued postoperative opioid use.”

If frequent nicotine use and existing mood disorders are predictors for persistent opioid use if not for a substance use disorder, doctors must consider this risk when prescribing those medications. “We need to increase awareness,” says Dr. Brummett. “Patients should not come in with a problem requiring surgery and leave with a different problem: opioid use.”

“It is a complication of surgery if patients are still taking opioids 90 days or more after the procedure,” says Brummett. “This constitutes an adverse outcome and primary care physicians should follow up to find out why patients are still using opioids so long after the surgery.”

The results of the study suggest that smokers and patients diagnosed with depression or anxiety—and especially people who have struggled with substance use before—are at a higher risk to develop an addiction, not because of their post-op therapy but because they have a particular predisposition.

Indeed, modern addiction treatment often needs to address exactly those co-occurring conditions matching the study’s cohort with “continued postoperative opioid use.” At Decision Point Center, therapy for addiction, substance use disorder and mental health issues includes an array of cutting-edge clinical and holistic methods. Addiction is a biopsychosocial disorder that requires addressing all aspects of the condition in the course of an individualized treatment plan. Treatment that fails to address those underlying conditions all too often results in a relapse of the patient.