Breast cancer

Mastectomy associated with risk of opioid dependence

Dr Jacob Cogan

Women who undergo mastectomy and breast reconstruction surgeries are at risk of becoming persistent users of opioids or sedative-hypnotic medications, according to new research conducted in the US and presented at the San Antonio Breast Cancer Symposium.

“It raises a flag across the board as something that maybe should be a routine thing that we pay attention to post-operatively,” said Dr Jacob Cogan, of Columbia University Medical Center in New York.

Other research has shown that the perioperative period is generally one of high risk for patients with cancer, with as many as 10% becoming new persistent opioid users after cancer-related surgery. The rates specifically surrounding mastectomy were not previously known, and less was known generally about dependence on sedative-hypnotics.

The researchers examined data from a healthcare insurance claims database including 25,270 opioid-naive patients, and 27,651 sedative-hypnotic-naive patients.

They found that in the opioid-naive group, 25.1% of patients did not fill any prescriptions for opioids, 61.8% filled a prescription only during the perioperative period (from 31 days prior to surgery through 90 days after surgery), and 13.1% were categorised as new persistent users, as they filled prescriptions during the perioperative period and at least twice during the postoperative period (from day 91 through day 365 after surgery).

For sedative-hypnotic medications, 61% were non-users, 32.4% were only perioperative users, and 6.6% became new persistent users.

Dr Cogan noted that if they removed those who never filled an opioid prescription from the analysis, 17.5% of those exposed to the drugs perioperatively then became new persistent users. Similarly, 17% of those exposed to sedative-hypnotics became new persistent users.

Several factors were associated with new persistent use of both opioids and sedative-hypnotics, including Medicaid insurance, breast cancer diagnosis (some in the cohort underwent prophylactic mastectomy without a diagnosis), chemotherapy treatment, and two categories of younger age (under 49 years and 50 to 64).

These risk factors were additive – with two factors, the odds ratio for becoming a new persistent opioid user was 2.27, but with five factors that increased to 6.34. For sedative hypnotics, those ORs were 2.55 with two risk factors and 7.71 with five.

“This is something that all physicians need to be aware of for their patients, this is something that we’re missing,” said Dr Virginia Kaklamani, of UT Health San Antonio and co-director of SABCS, and who was not involved with the research.

“It’s easy to just give a prescription instead of arguing with a patient about why you’re not going to give them a prescription,” she said during a press briefing.

Dr Kent Osborne, of Baylor College of Medicine and another co-director of SABCS, noted that some surgeries tend to be less painful than others, and perhaps shouldn’t involve opioid prescriptions at all.

“A lot of my patients, they get the prescription but they don’t even use them,” he said. “And I wonder if it’s given just so that we’re not bothered at night time by someone calling with pain.”

Dr Kaklamani said there should perhaps be a move toward other forms of pain management, including physical therapy and rehabilitation.

“It’s much harder to do that than to send a prescription in for a narcotic, but that easy answer is [usually] the worst answer.”

Disclosure statement: Dr Cogan reports no conflicts or financial disclosures. Dr Kaklamani has received speaker fees from and acted as a consultant for several pharmaceutical companies, and has received research funding from Eisai. Dr Osborne is on data monitoring committees with Lilly and Tolmar, and is on the advisory board for GeneTex. 

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