Postsurgical Opioid Refills Risky for Entire Household

Postsurgical opioid refills are associated with an increased risk for opioid misuse among family members — and the more refills, the higher the risk, new research suggests.

Further results showed that if a surgical patient became a chronic opioid user, the likelihood of a family member misusing these drugs increased 2.5 times.

“Patients requiring ongoing opioid refills should set off alarm bells,” study investigator Gabriel A. Brat, MD, assistant professor of surgery at Beth Israel Deaconess Medical Center and instructor in biomedical informatics at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

“It should prompt providers to ask themselves if the patient’s course of management needs to be adjusted because the opioids aren’t providing the recovery they’d like, or if by continuing on the existing course of putting refills they’re the family at risk ,” Brat said.

The findings were published online July 15 in JAMA Network Open.

Impact on Families

Previous research has linked opioid exposure to misuse in discharged surgical patients. “We were interested in understanding if that exposure was also impacting the family,” said Brat.

The current study included patients and family members from an administrative database that stores information on more than 35 million individuals. Participants were receiving health and pharmacy insurance coverage under this commercial insurance provider.

Investigators assessed all opioid prescriptions filled by the patient in the 90 days after surgery. They considered several measures of opioid exposure for the patient, including a number of opioid refills and long-term exposure to opioids, defined as longer than a 90 days’ supply.

Family members were aged 15-64 years and mainly included spouses, children, and parents. Outcomes for family members were opioid misuse (defined as dependence, abuse, or overdose) and chronic opioid use longer than 90 days in the 12 months following the patient’s date of surgery.

The analysis included 843,531 unique pairs of a patient and family member. Most pairs comprised female patients (52.8%) and male family members (52.5%), with many pairs that had patients aged 45-54 (29.6%) and with family members aged 15-24 (37.2%).

About 36% of pairs were in households with no opioid prescriptions, and 47.1% were in households where the patient received only one initial opioid prescription. In 16.9% of pairs, the patients obtained at least one refill.

There were 3894 opioid misuse events (0.5%) and 7485 chronic opioid use events (0.9%) in family members.

More Prescriptions, More Risk

Results showed that, after adjusting for covariates, filling only an initial prescription without any refills did not appear to increase risk for opioid misuse or chronic opioid use in family members compared with having no opioid prescription.

However, each additional opioid prescription refill for the patient was associated with a 19.2% (95% CI, 14.5% – 24.0%) increase in hazard of opioid misuse in the family member.

In addition, each additional week of opioid exposure to the patient was associated with a 12.3% (95% CI, 8.9% – 15.8%) increase in risk of opioid misuse in the family member.

When the patient became a chronic opioid user, the hazard ratio (HR) for opioid misuse among family members was 2.52 (95% CI, 1.68 – 3.80), with similar patterns for family members’ chronic opioid use.

“That’s substantial,” said Brat, who called this result “one of the most striking pieces of information” in the study.

“It means that if my wife undergoes surgery and requires long-term opioids, the risk [for opioid misuse] to me or my daughter or someone else in our family is two and a half times what it would be otherwise,” he noted.

The estimated probability of opioid misuse was greatest among younger family members in their early 20s, whereas the estimated probability of chronic opioid use was highest among older family members (mid-60s).

“Concerning Scenario”

The study did not break down risks according to surgery type. However, Brat said certain orthopedic procedures are linked to higher rates of opioid prescriptions.

The increased risk of misuse and chronic use of opioids among family members could be explained by their diverting leftover opioids, he noted. Moreover, the shared environment between a family member and patient may somehow trigger familial risk and the sharing of pills.

Common genetic factors may also play some role in increasing the risk.

Brat noted the study does not place blame on doctors, patients, or family members for opioid misuse; but a surgeon allowing multiple refills for the patient “is certainly a concerning scenario,” he added.

“At least from our data, those refills themselves are a sign the family is going to be at risk,” he said.

The opioid epidemic has resulted in surgeons being more aware of the risks these drugs pose. “They’re trying to balance providing effective pain control to their patients with doing what’s safe for those patients,” said Brat.

The new results “empower” these doctors to have “more frank conversations” with patients about the risks of household opioid misuse, he noted.

“They can say to them that every opioid prescription puts not only you but your family at the risk of having a misuse event,” he added.

Conservative Estimates?

Commenting on the findings for Medscape Medical NewsTraci Speed, MD, PhD, assistant professor of psychiatry and behavioral sciences and director of psychiatric services, Personalized Pain Program, Johns Hopkins University, Baltimore, Maryland, said the well-designed study provides evidence of household risks of opioid use at the population level.

However, she noted that capturing opioid-related risks from data using diagnostic codes may underestimate the rates of opioid misuse and chronic opioid use.

“So these findings are likely conservative estimates,” said Speed, who was not involved with the research.

“It’s important that providers, patients, and the public understand that prolonged opioid prescribing after surgery may increase opioid-related risks among households,” she said.

Additional studies are now warranted to provide evidence on the risks of postoperative opioid prescription refills at the individual- and family-level, Speed ​​added.

The study was funded by grants from the Department of Biomedical Informatics at Harvard Medical School, Aetna Inc, the US National Library of Medicine/National Institutes of Health, Biomedical Informatics and Data Science Research Training Program of Harvard University, CRICO/Risk Management Foundation of Harvard Medical Institutions, and a Blavatnik Biomedical Accelerator Pilot Grant from Harvard University. Brat has reported no relevant financial relationships.

JAMA Netw Open. Published online July 15, 2022. Full text

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