Preoperative depression and postoperative opioid use

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Presenting at the 2019 American Association of Gynecologic Laparoscopists (AAGL) Global Congress in Vancouver, Erin T. Carey, MD, discussed her findings that women with preoperative depression are at a greater risk of increased opioid use following hysterectomy. Preoperative depression has been linked to several adverse outcomes following the procedure, including increased acute and chronic postoperative pain.

Methods
The retrospective analysis included women who underwent benign hysterectomy between January 2001 and March 2015. Women without opioid prescriptions 180 days prior to surgery were identified through a large claims database and were required to have continuous enrollment in a trackable health plan for 180 days before and after hysterectomy. For this study, the authors defined persistent opioid use as an opioid fill during the perioperative period (10 days before to 30 days after surgery) and an additional opioid fill 90 to 180 days after hysterectomy.

Dr. Carey explained, “Persistent opioid use has many definitions depending on how the authors seem to define it. What we thought was clinically meaningful was an opioid fill during the perioperative period…and then if the patient had an additional fill after 90 days.”

The authors used multivariable log-binomial regression to assess whether women with preoperative depression were at a higher risk of persistent opioid use and 30-day complications.

Findings
Of the 531,059 eligible women who underwent hysterectomy for non-cancer causes during the study period, 72% (n = 383,243) were opioid naive and included in the study.  The prevalence of surgical depression was 20% (n = 75,230). Seventy-four percent of women were given an opioid prescription during the perioperative period and, of those who initiated, 8% refilled the prescription at least once 90-180 days after the procedure. After adjusting for potential confounders, women with depression were only 8% more likely to get an initial opioid fill (RR 1.08, 95% CI 1.07 – 1.08). However, these women were 43% more likely to have persistent opioid use (RR 1.43, 95% CI 1.39-1.47). Women with depression were also more likely to have a surgical complication (RR 1.04, 95% CI 1.03, 1.06).

Conclusions
Based on the study findings, women with preexisting depression had a greater risk of persistent opioid use following hysterectomy, suggesting chronic pain beyond the immediate recovery period. These patients may also be at an increased risk for opioid dependence.

Dr. Carey noted that “This data is consistent with the other data that potentially a de novo postoperative opioid dependence may be a higher risk with patients with preexisting depression, so it is important for ob/gyns to look at that critically.”