1 in 5 patients prescribed opioids after CIED procedures

Short-term opioid prescriptions could have long-term consequences for heart patients with cardiac implantable electronic devices (CIEDs), according to work published in Heart Rhythm Oct. 21.

The use and abuse of opioids in the U.S. isn’t a novel topic in medicine, first author Justin Z. Lee, MD, of Mayo Clinic Arizona, and colleagues wrote in the journal—the country is well-aware it’s in the thick of an addiction epidemic. The Trump administration declared a national public health emergency on the topic two years ago, but Lee et al. trace the roots of the crisis back to 2001.

That was when the Joint Commission on Accreditation of Healthcare Organizations rolled out its new Pain Management Standards, which pushed the idea of pain as the “fifth vital sign” and recommended that physicians ask all their patients about pain symptoms. Opioid prescriptions began to surge after the document went public, ultimately resulting in a prescription overdose death rate that exceeded that of cocaine and heroin.

“Provider attitudes about pain control may be influenced by pain management training and previous experiences,” Lee and co-authors wrote. “Patient factors, such as expectations of pain control, underlying comorbidities and personal sensitivity to pain are intertwined with the social norms about pain control and the perceived ability of the healthcare provider to provide pain control. All of these factors influence the provider’s decision to prescribe opioids.”

But, in spite of wide-ranging research on the subject, there’s a lot we don’t know about opioids in cardiology, the authors said. Researchers lack data on opioid prescriptions and refills after CIED implantations despite the fact that the procedures are somewhat invasive.

Lee and colleagues retrospectively analyzed 16,517 patients who underwent CIED procedures at Mayo Clinic practices in Minnesota, Arizona and Florida between 2010 and 2018. Procedures were categorized as either new implants, generator changes, device upgrades, lead revisions or replacements, or subcutaneous implantable cardiac defibrillator procedures.

The authors reported that 20.2% of patients in the study population were prescribed opioids after a CIED procedure—80% of whom were opioid naive before the procedure. Nine-point-four percent of opioid recipients who were initially opioid naive ended up refilling their prescriptions.

“This finding suggests that perioperative pain management in CIED procedures warrants meticulous attention,” the team noted.

The percentage of patients who received more than 200 oral morphine equivalents of prescription in the study was 38.8%, Lee et al. wrote. Temporal trends revealed increasing rates of opioid prescription through 2015, at which point they peaked at 25.9%, but decreased after that, settling at 14.6% in 2018.

The researchers said the opioid prescription rate in their study falls somewhere in the middle of current research on the topic. Their rate was higher than that observed with some interventional radiology procedures, but compared to other interventions—research has found a 59% opioid prescription rate after endovascular aneurysm repair, for example, and a 77% prescription rate after hand surgery procedures—it was low. They wrote the discrepancy could be due to the fact that CIED procedures, compared to other surgeries, are less invasive and risky.

“This study shows that perioperative pain management in CIED procedures warrants attention,” Lee and co-authors said. “More studies are needed to evaluate various methods to decrease opioid prescription rates following CIED procedures, such as development of protocols emphasizing nonopioid means of pain relief that can reduce the use of opioids following CIED procedures.”