Association between complications after vascular surgery and prolonged postoperative opioid use

Objective — Few studies have looked at the long-term risk of opioid use following major vascular surgery and no study has investigated the potential association between major complications and prolonged opioid use. We analyzed a population-based database linked to a prescription database to investigate factors associated with prolonged opioid use following major vascular surgery.

Methods — This population-based cohort study included all adults who underwent open lower extremity revascularization (LER) or non-ruptured abdominal aortic aneurysm repair (open [AAA] and endovascular [EVAR]) in the province of Ontario, Canada, between 2013-2018. Prolonged opioid use was defined as 2 or more opioid prescriptions filled 6-12 months following surgery. Potential predictors of prolonged use were explored using modified Poisson regression with a generalized estimating equation (GEE) approach to account for the clustering of patients within physicians and institutions.

Results — This study included a total of 11,104 patients with 5,652 patients undergoing open LER, 3,285 patients undergoing EVAR, and 2,167 patients undergoing AAA. The rates of prior opioid use were 35.4% for LER, 15.8% for AAA and 14.3% for EVAR. Major complication rates following each procedure were 59.5% for AAA, 35.1% for LER, and 21.0% for EVAR. Following surgery, prolonged opioid use was identified in 26.1% of LER, 13.2% of AAA, and 11.6% of EVAR patients. The strongest predictor of prolonged opioid use was prior use with an OR of 13.27 (95%CI10.63-16.57) for AAA, 11.24 (95%CI 9.18-13.75) for EVAR, and 4.69 (95%CI 4.16-5.29) for LER. The occurrence of a major complication was only associated with prolonged opioid use for patients undergoing LER (OR 1.10; 95% CI:1.03-1.19), while it had a protective effect on patients undergoing EVAR (OR 0.83; 95% CI 0.69-0.99) and no association for patients undergoing open AAA repair (OR 1.11; 95% CI: 0.95-1.29). Older age was also protective with a reduced rate of prolonged opioid use for every 10 years of age increase: AAA (OR 0.87; 95% CI 0.77-0.99); EVAR (OR 0.83; 95% CI: 0.76-0.91); and LER (OR 0.91; 95% CI: 0.87-0.94).

Conclusions — Prolonged opioid use is common following major vascular surgery, occurring in over 10% of patients undergoing either open or endovascular aneurysm repair and over 25% of patients undergoing open lower extremity revascularization. Prior opioid use is the strongest predictor for prolonged use, while the occurrence of postoperative complications is associated with a slight increased risk of prolonged use in patients undergoing lower extremity revascularization. These patient populations should be targeted for multimodal methods of opioid reduction following their procedures.