Risk Factors Identified for Chronic Opioid, Benzodiazepine Use After Mastectomy and Breast Reconstruction

An abstract presented at last month’s San Antonio Breast Cancer Symposium outlines possible contributors to long-term use of controlled substances after treatment of breast cancer with mastectomy plus breast reconstruction in women who were prescribed opioids, benzodiazepines, and nonbenzodiazepine sedatives/hypnotics.

“It has become clear that short-term exposure to opioids for any reason can lead to long-term dependence, given the highly addictive potential of these agents,” said lead author, Jacob Cogan, MD, hematology/oncology fellow at NewYork Presbyterian/Columbia University Irving Medical Center, in a statement. “Many patients receive this initial exposure around the time of surgery, and patients with cancer are at particularly high risk of becoming dependent on opioids post-operatively.”

This retrospective study used the IBM MarketScan health care claims database to extract data from 2008 through 2017 on women who had a mastectomy and reconstruction. Three periods were used to evaluate opioid, benzodiazepine, and nonbenzodiazepine prescription patterns among women who were not previous users of these classes of drug (n = 26,264; 29,163; and 34,388, respectively):

• Preoperative: 365 to 31 days before surgery
• Perioperative: 31 days before to 90 days after surgery
• Postoperative: 90 to 365 days after surgery

Overall, 12.1% (odds ratio [OR], 1.45; 95% CI, 1.04-2.02), 5.3% (OR, 1.82; 95% CI, 1.06-3.13), and 2.6% (OR, 1.50; 95% CI, 0.77-2.93) of the women had chronic opioid, benzodiazepine, and nonbenzodiazepine use, respectively, following their mastectomy and breast reconstruction. Chronic use was defined as filling at least 1 and 2 prescriptions in the peri- and postoperative periods, respectively.

Following multivariable logistic regression analysis, the contribution of younger age (≤39 years and 40-69 years), having Medicaid coverage, and receiving a mental health or substance use diagnosis to the women’s increased risk of becoming a new chronic user was common across the classes:

• Opioid:
  • Age 39 years and younger (OR, 1.63; 95% CI, 1.26-2.11; P = .0002)
  • Having Medicaid coverage (OR, 1.37; 95% CI, 1.11-1.68; P = .003)
  • Receiving a mental health diagnosis (OR, 1.66; 95% CI, 1.54-1.79; P < .0001)
  • Receiving a substance use diagnosis (OR, 1.93; 95% CI, 1.64-2.26; P < .0001)
• Benzodiazepine:
  • Age 39 years and younger (OR, 1.67; 95% CI, 1.14-2.44; P = .009)
  • Having Medicaid coverage (OR, 1.30; 95% CI, 1.02-1.669; P = .04)
  • Receiving a mental health diagnosis (OR, 3.78; 95% CI, 3.37-4.24; P < .0001)
  • Receiving a substance use diagnosis (OR, 1.62; 95% CI, 1.32-1.98; P < .0001)
• Nonbenzodiazepine:
  • Age 40 to 69 years (OR, 2.00; 95% CI, 1.19-3.34; P = .009)
  • Having Medicaid coverage (OR, 1.05; 95% CI, 0.74-1.48; P = .8)
  • Receiving a mental health diagnosis (OR, 2.22; 95% CI, 1.93-2.56; P < .0001)
  • Receiving a substance use diagnosis (OR, 1.58; 95% CI, 1.22-2.04; P = .0005)

A positive correlation was seen between the number of risk factors and the risk of becoming a persistent user.

Receiving chemotherapy was an additional risk factor for chronic controlled substance use, with respective odds of 1.35, 2.20, and 1.92, showing that its influence varied across the classes.

These results do not suggest avoiding these drug classes, Cogan noted. “Rather, patients should be vigilant about taking these medications only when necessary, and they should work closely with the prescribing provider to attempt to minimize risk of dependence,” he said.

Additional attention must be paid to those who have also received a mental health or substance use diagnosis, the authors noted.

A possible study limitation is inaccuracy of claims submitted to insurance companies.

Reference

Cogan JC, Raghunathan RR, Beauchemin MP, et al. Persistent controlled substance use following mastectomy with reconstruction surgery. Presented at: 2020 San Antonia Breast Cancer Symposium; December 8-11, 2020. Abstract GS3-08.