Women who have undergone mastectomy and reconstructive surgery may face an elevated risk for persistent use of opioids and sedative-hypnotic drugs than previously suspected, according to a retrospective cohort study presented at the San Antonio Breast Cancer Symposium (SABCS), held virtually December 8-11, 2020.
Results showed that 13.1 percent of opioid-naive patients became persistent opioid users after mastectomy and reconstruction, while 6.6 percent of sedative-hypnotic-naive patients became new persistent sedative-hypnotic users. When removing "non-users"-those who did not fill controlled substance prescriptions 31 days prior to or 90 days after surgery-the rates rose to 17.5 percent and 17 percent, respectively.
The study also identified factors that could predict which patients might be vulnerable to persistent use of narcotics and other controlled substances, including age, insurance, type of therapy, and previous mental health or substance abuse issues.
"The biggest thing is just how striking how many patients this is an issue for just across the board," said the study's lead author, Jacob Cogan, MD, a fellow in hematology/oncology at NewYork-Presbyterian/Columbia University Irving Medical Center. "It's much more than I may have thought prior to doing the study."
Carlos Arteaga, MD, Director of the Simmons Comprehensive Cancer Center and Associate Dean of Oncology Programs at UT Southwestern Medical Center, said he was unaware of any previous studies linking sedatives and hypnotics to persistent use following mastectomy and reconstruction.
"I think this is an original observation," noted Arteaga, former AACR president and Co-Director of the SABCS.
As underscored by Cogan during a press briefing, the management of pain for cancer patients during an "opioid epidemic" has raised concerns about its persistent use following treatment.
For this study, Cogan and colleagues focused on persistent drug use-including opioids and sedative-hypnotics drugs-among women who have undergone mastectomy and reconstructive surgery, both with and without a diagnosis of cancer.
"Previous studies have not compared postoperative opioid use between those with and without a diagnosis of cancer," Cogan and colleagues wrote in an abstract for the symposium. "Furthermore, it is unknown if a similar pattern exists regarding the use of benzodiazepines (benzos) and other non-benzo sedatives/hypnotics (N-benzos) after mastectomy and reconstruction."
To fill in this knowledge gap, the researchers used the MarketScan health care claims database to evaluate women older than 18 years of age who underwent mastectomy and reconstructive surgery between the years 2008 and 2017. The team identified prescriptions for opioids, benzos, and N-benzos during three periods: 365 days to 31 days prior to surgery (preoperative), defined as period 1; 31 days prior to 90 days after their surgery (perioperative), or period 2; and 90 days to 365 days after surgery (postoperative), or period 3.
The researchers identified 25,270 women who were not prior users of opioids and 27,651 who were not prior users of sedative-hypnotics. Patients who used controlled substances prior to surgery, who filled at least one prescription for a given agent during period 1, were excluded from the study. Patients who had no use in period 1 but filled at least one prescription in period 2 and at least two prescriptions in period 3 were considered new chronic users and were compared to the other non-chronic users.
Among patients at greatest risk for persistent drug use were women under the age of 65, those with Medicaid insurance, a diagnosis of breast cancer (versus those who had prophylactic surgery), receipt of chemotherapy, mental health diagnosis, and substance use diagnoses. Similar results were seen with other drug categories.
"Obviously, the risk factors we point out are people who deserve particular attention," said Cogan, "but I think it sort of raises the issue that as a provider when you're seeing patients and follow-up, there's something you might want to explicitly ask about and not just assume the postoperative opioids were taken and disposed of."
He said the study results should not suggest that opioids and sedative-hypnotic drugs be avoided.
"We certainly don't want to imply from our study that people shouldn't be getting these prescriptions if they need them," Cogan noted. "But I think the issue is, once they have them, don't just sort of leave them there at their homes because other studies have shown that's when people really get addicted to these medications."
Warren Froelich is a contributing writer.