The Dangers of Persistent Controlled Substance Use After Surgery-Related Prescriptions

Increased prescription of opioid medications has led to a nationwide epidemic and public health emergency. The number of drug overdose deaths in the U.S. has quadrupled since 1999, with more than 70% of all cases in 2019 involving an opioid. 

Two new studies from researchers at the Herbert Irving Comprehensive Cancer Center (HICCC) highlight the risk of prolonged substance use in patients undergoing cancer-related surgical procedures after being prescribed opioids or sedative-hypnotic medications. The studies were led by Dawn L. Hershman, MD, director of Breast Oncology and co-leader of the Cancer Population Science program at the HICCC, along with first authors Jacob C. Cogan, MD and Jason D. Wright, MD. 

The first study, published online June 4 in the journal Breast Cancer Research and Treatment, found that women undergoing mastectomy and reconstructive surgery who receive a prescription for opioid or sedative-hypnotic medications around the time of surgery are at risk for prolonged use of these controlled substances post-operatively. While such prescriptions are generally intended to provide relief of short-term, surgery-related pain and anxiety, there appears to be a significant amount of long-term use after this peri-operative exposure.

In a cohort of 23,025 patients who were not taking opioids prior to surgery, three out of four filled an opioid prescription related to surgery, and subsequently, almost one in five of those women became persistent opioid users who continued to fill prescriptions up to a year later. A similar rate of new persistent use was seen in the 25,046 patients who were not taking sedative-hypnotic medications (such as Ativan and Ambien) before surgery. While fewer patients (9,426) filled a sedative-hypnotic prescription related to their surgery, again one in five continued to fill prescriptions up to one year post-operatively. Risk factors such as age <65, Medicaid insurance, a diagnosis of breast cancer and treatment of chemotherapy increase the chances of a patient becoming a long-term user of controlled substances.

“I hope that our study raises awareness that even a brief exposure to these addictive medications for surgery-related pain or anxiety can lead to long-term use,” says Dr. Cogan, Columbia hematology/oncology fellow. “Both patients and providers should be aware of this issue, and of the risk factors that elevate an individual patient’s risk.”

The other study focused strictly on benzodiazepine prescriptions that led to persistent use among patients who had common surgical procedures. Misuse of benzodiazepines like Valium (diazepam) and Xanax (alprazolam) can lead to severe physical and mental addiction. The rate of overdose deaths from benzodiazepines in the U.S. increased four-fold from 1996 to 2010. 

The study, published online June 3 in the journal JAMA Network Open, included a total of 2,509,599 adults who underwent a major or minor surgical procedure such as cataract surgery, colectomy, or appendectomy. Within this group, a relatively small percentage of patients ended up using benzodiazepines, with only 2.6% filling one or more prescriptions for the substance in the months after surgery. However, similar to the opioid use study, one in five of these individuals went on to become persistent users. 

“These findings suggest that benzodiazepines should only be used in patients with a clear indication and attempts made to limit the quantity and duration of use. Similar efforts have been successfully utilized to reduce perioperative opioid prescription use,” says Dr. Wright, chief of the division of gynecologic oncology at NewYork-Presbyterian/Columbia University Irving Medical Center.

Both studies emphasize that exposure to addictive controlled substances, like opioids and benzodiazepines within the context of a surgical procedure, has a high potential for misuse. The researchers stress that providers should make every effort to manage prescriptions that come with such risk, including limiting the quantity and duration of use, considering safer alternative medications, and raising awareness among patients. 

“These studies show that we need to be aware that 20% of patients who are prescribed any type of controlled substances may continue to take these medications long-term,” says Dr. Hershman. “Better systems to rapidly taper patients off of medications are needed to assist patients who may need them for short term use.”