title: Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System.
abstract: This study aims to determine 1) the epidemiology of perioperative opioid use; and 2) the association between patterns of preoperative opioid use and time-to-cessation of postoperative opioids.
  
  
  
  Retrospective, cohort study.
  
  
  
  National, population-level study of Veterans Healthcare Administration (VHA) electronic clinical data.
  
  
  
  All VHA patients (n = 64,391) who underwent surgery in 2011, discharged after stays of ≥1 day, and receiving ≥1 opioid prescription within 90 days of discharge.
  
  
  
  Patients' preoperative opioid use were categorized as 1) no opioids, 2) tramadol only, 3) short-acting (SA) acute/intermittent (≤ 90 days fill), 4) SA chronic (> 90 days fill), or 5) any long-acting (LA). After defining cessation as 90 consecutive, opioid-free days, the authors calculated time-to-opioid-cessation (in days), from day 1 to day 365, after hospital discharge. The authors developed extended Cox regression models with a priori identified predictors. Sensitivity analyses used alternative cessation definitions (30 or 180 consecutive days).
  
  
  
  Almost 60% of the patients received preoperative opioids: tramadol (7.5%), SA acute/intermittent (24.1%), SA chronic (17.5%), and LA (5.2%). For patients opioid-free preoperatively, median time-to-cessation of opioids postoperatively was 15 days. The SA acute/intermittent cohort (HR =1.96; 95% CI =1.92-2.00) had greater risk for prolonged time-to-cessation than those opioid-free (reference), but lower risk than those taking tramadol only, SA chronic (HR = 9.09; 95% CI = 8.33-9.09), or LA opioids (HR = 9.09; 95% CI = 8.33-10.00). Diagnoses of chronic pain, substance-use, or affective disorders were weaker positive predictors. Sensitivity analyses maintained findings.
  
  
  
  Greater preoperative levels of opioid use were associated with progressively longer time-to-cessation postoperatively.
authors.affiliation: *Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California mudumbai@stanford.edu.
authors.forename: Seshadri C
authors.initials: SC
authors.lastname: Mudumbai
authors.affiliation: Program Evaluation and Resource Center; and Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Oliva
authors.affiliation: Program Evaluation and Resource Center; and Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
authors.forename: Eleanor T
authors.initials: ET
authors.lastname: Lewis
authors.affiliation: Program Evaluation and Resource Center; and Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
authors.forename: Jodie
authors.initials: J
authors.lastname: Trafton
authors.affiliation: Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts.
authors.forename: Daniel
authors.initials: D
authors.lastname: Posner
authors.affiliation: *Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: Edward R
authors.initials: ER
authors.lastname: Mariano
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California, Health Economics Resource Center, Menlo Park, California; Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and Department of Health Research and Policy, Stanford University, Stanford, California, USA.
authors.forename: Randall S
authors.initials: RS
authors.lastname: Stafford
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California, Health Economics Resource Center, Menlo Park, California; Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and Department of Health Research and Policy, Stanford University, Stanford, California, USA.
authors.forename: Todd
authors.initials: T
authors.lastname: Wagner
authors.affiliation: *Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: J David
authors.initials: JD
authors.lastname: Clark
mesh_terms: D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000188:drug therapy*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D014728:Veterans
chemical_list: D000701:Analgesics, Opioid
keywords: Cessation; Long-Acting Opioids; Perioperative; Pharmacoepidemiology; Short-Acting Opioids; Surgery