Opioid use after open resection or video-assisted thoracoscopic surgery for early-stage lung cancer
Menée à partir des données des registres américains des cancers portant sur 3 900 patients atteints d'un cancer du poumon non à petites cellules de stade I traité entre 2007 et 2013 et menée à partir des données de la base Medicare, cette étude analyse l'utilisation des opioïdes après une résection par voie ouverte et une chirurgie thoracoscopique assistée par vidéo, puis identifie les facteurs associés au risque d'utilisation à long terme des opioïdes
Patients undergoing surgery for early-stage lung cancer often experience persistent postoperative pain; it has been estimated that in 10% of patients the pain can be so intense as to be debilitating.1 While the current standard of care is to prescribe opioids at discharge, this treatment is intended as short-term pain control, not to exceed a few weeks after surgery.2 Medical prescriptions of opioids increase the risk of opioid abuse and overdose.3 Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical technique used in early-stage lung cancer that might reduce the need for opioids compared with traditional open surgery,4 but this has yet to be established. Methods : The Surveillance, Epidemiology, and End Results linked to the Medicare database was queried to identify patients with stage I primary non–small cell lung cancer who had VATS or open resection between January 1, 2007, to December 31, 2013, the years in which Medicare Part D data are available. Patients were excluded from analysis if they had a record of opioid medication prescribed in the 30 days before surgery; thus, we included only opioid-naive patients. Long-term opioid use was defined as having filled 1 or more prescriptions in the first 90 days after surgery as well another prescription in the 90 and 180 days after surgery.5 Multivariable logistic regression and propensity score matching were used to investigate the associations between surgical type and long-term opioid use. Data analysis was performed between November 3, 2017, to May 15, 2018. The study was approved by Icahn School of Medicine at Mount Sinai Institutional Review Board with waiver of informed consent. Results : There were 3900 patients with non–small cell lung cancer included in this analysis: 1987 VATS (50.9%) and 1913 open resection (49.1%) patients. A total of 2766 patients (70.9%) were discharged with an opioid prescription, and 603 (15.5%) patients had a record of long-term postoperative use. Patients who underwent VATS were more likely to be women; older; have a smaller tumor, adenocarcinoma, limited resection, and a lower comorbidity score; belong to a higher income quartile; and live in an urban area. Patients who underwent VATS were significantly less likely to have filled an opioid prescription within 90 days after surgery, had a smaller number of overall opioid prescriptions filled than open resection patients, and were less likely to be long-term opioid users (Table 1). In the adjusted model, patients were significantly less likely to use opioids long-term if they had VATS (adjusted odds ratio [aOR], 0.69; 95% CI, 0.57-0.84), were older (aOR, 0.96, 95% CI 0.94-0.98), and had higher income (aOR, 0.77, 95% CI 0.60-0.99). Long-term opioid use was significantly more likely in those with a higher comorbidity score (aOR, 1.10; 95% CI, 1.05-1.16), large-cell histology (aOR, 1.88; 95% CI, 1.17-3.00), using sleep medication 30 days before surgery (aOR, 1.72; 95% CI, 1.28-2.32), and with a previous psychiatric condition (aOR, 1.64; 95% CI, 1.28-2.09). After propensity matching, the risk of long-term opioid use was still significantly less in patients who underwent VATS (aOR, 0.52; 95% CI, 0.36-0.75) (Table 2). Discussion : A total of 15.5% of patients who were not previous opioid users became long-term opioid users after surgery. Our study suggests that surgical invasiveness might play a role in the odds of becoming a long-term opioid user after surgery; patients undergoing VATS were less likely to use opioids both in the immediate postoperative period and long-term, even after adjusting for relevant covariates. A limitation of this claim-based study is the precision of the measurement: we cannot discount, for example, that patients may have been able to acquire opioids from friends or family members. However, this possibility suggests that we are likely underestimating the true proportion of long-term opioid users. The escalating severity of the opioid epidemic in the United States6 highlights the need for additional research into how pain management after surgery might be a contributing factor.
JAMA Oncology 2018