Study Finds Increased Opioid Use in PAD Patients
October 30, 2019—The Society for Vascular Surgery (SVS) announced that a large new study has found that peripheral artery disease (PAD) is associated with increased use of opioids. The investigators discovered that some patients who had a procedure to improve pain from poor circulation actually increased their use of opioids after treatment.
The findings were published by Nathan K. Itoga, MD, et al in Journal of Vascular Surgery (2019;70;1271–1279). The online article includes an mp3 attachment containing a recording of a discussion on these findings.
According to SVS, the investigators looked at 178,880 deidentified patients in a private health insurance database over an 8-year period who were found to have PAD. More than one-third of these patients had critical limb ischemia (CLI).
Dr. Itoga commented in the SVS announcement, "The first thing that surprised us is that a significant number of PAD and CLI patients were already on opioids when they had their first PAD diagnosis. After they were diagnosed with either condition, the percentage receiving opioids went up and it also went up after they had a procedure to address their disease."
As summarized by SVS, the investigators found that high opioid use increased from 25.8% in the years before treatment to 29.6% in the years after treatment. For patients without CLI, high opioid use increased from 22.7% before treatment to 25.9% after treatment and from 30.8% before treatment to 37.1% after treatment for patients with CLI.
The study found that high-opioid-use patients were more likely to have back and neck pain, be smokers, and/or have depression. High opioid use was defined in the study as patients who were prescribed two or more opioid prescriptions in a year.
The study did not determine where the additional opioids came from, Dr. Itoga said, "but having PAD would not be a routine reason for a physician to prescribe opioids, unless the patient has resting pain or open wounds." He theorized that it is possible that higher opioid use after surgery is akin to a prescription side effect for a small percentage of patients in chronic pain.
Dr. Itoga noted, "Before this research and the opioid crisis, I would have sent a patient home from open surgery with perhaps 60 pills. Now I prescribe 10 to 15 pills. And previously, for someone who had an endovascular procedure, I used to send them home with opioids in case they needed them. Now I tell them to take over-the-counter medication if they need it." Further, he acknowledged that the pain from PAD is real. Early on, patients may have the cramping sensation of claudication, which mostly occurs while walking. If the disease progresses untreated, painful open sores on the feet can occur, and if PAD leads to CLI and amputation, that postoperative pain needs strong medication management.
"It's a tough decision for physicians," stated Dr. Itoga. "The patients are in pain and suffering. You don't want to ignore it, but you don't want them to become addicted. We just want to make people aware."
SVS noted that physicians are prescribing with more caution. In an October 2018 press release addressing proposed federal legislation related to the opioid crisis, the society affirmed its support while ensuring that physicians maintain the ability to prescribe what is best for their patients without regulatory interference.