Can Surgery Type Predict Opioid Abuse in NSCLC?

Patients who undergo a minimally invasive procedure for non-small-cell lung cancer (NSCLC) are less likely to use opioids long-term and use less painkillers overall than patients who undergo open resection, according to a new study.

“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,” wrote study authors led by Stephanie Tuminello, MPH, of the Icahn School of Medicine at Mount Sinai in New York. “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. Medical prescriptions of opioids increase the risk of opioid abuse and overdose.”

The authors used data from the Surveillance, Epidemiology, and End Results (SEER) database to examine opioid use following video-assisted thoracoscopic surgery (VATS) and open resection for stage I primary NSCLC. Patients were treated between 2007 and 2013.

The study results were published online in JAMA Oncology.

Among 3,900 total patients, 1,987 underwent VATS (50.9%) and 1,913 underwent open resection (49.1%). Those who underwent VATS were more likely to be female (63.2% vs 36.8%; P < 0.001), and they had smaller tumors, lower comorbidity scores, and were more likely to belong to a higher income quartile and live in an urban area.

A total of 2,766 patients were discharged following the procedure with an opioid prescription (70.9%), and 603 patients (15.5%) had a record of long-term postoperative use of opioids.

Short-term opioid use (0–90 days) was more frequent in open resection patients (74.5%) than in VATS patients (67.6%; P < 0.001). The same was true for long-term opioid use (>90 days to <180 days), at 19.1% in open resection patients and 11.9% in VATS patients (P < 0.001). The mean number of opioid prescriptions was 2.06 in open resection patients and 1.38 in VATS patients (P < 0.001).

In an adjusted model, compared with open resection, VATS had an odds ratio (OR) for long-term opioid use of 0.69 (95% CI, 0.57–0.84). This was still true in a propensity-matched model involving 1,066 patients, with an OR of 0.52 (95% CI, 0.36–0.75). Long-term use of opioids was more likely in patients with higher comorbidity scores, large-cell histology, in those who used sleep medication 30 days before surgery, and in those with a previous psychiatric condition.

“Our study suggests that surgical invasiveness might play a role in the odds of becoming a long-term opioid user after surgery,” the authors wrote. “The escalating severity of the opioid epidemic in the United States highlights the need for additional research into how pain management after surgery might be a contributing factor.”

 Alexander A. Brescia, MD, of the University of Michigan, who was not involved in the study but led a study that came to similar conclusions, called these results significant. “While increased opioid usage after thoracic surgery has been previously documented, the difference in long-term opioid usage rates by surgical approach in this analysis is striking,” he told Cancer Network, adding that the rate of open thoracotomy was particularly high considering these were phase I malignancies where minimally invasive approaches are generally recommended.

“As thoracic surgery patients have been shown to have the highest rate of new long-term opioid usage among post-surgical populations, thoracic surgeons and oncologists should be aware of this risk factor and the additional risk conferred by a more invasive surgical approach,” Brescia said. “When successful oncologic resection is feasible through a VATS approach, as it should be for the majority of stage I non-small cell lung cancer, a minimally-invasive approach for resection should be pursued.”