Women With Breast Cancer Who Receive Mastectomy and Reconstructive Surgery at Greater Risk for Continued Opioid, Controlled Substance Use

Women who received reconstructive surgery after a mastectomy, a breast cancer diagnosis, those who received chemotherapy and were a young age were more likely to have a higher risk of new chronic controlled substance use, according to data presented at the 2020 San Antonio Breast Cancer Symposium.

The data, according to lead study author Dr. Jacob Cogan, highlights that more attention is needed for patients with mental health and substance use diagnoses when managing any pain, anxiety and sleep disorders they may be experiencing following breast cancer diagnosis or treatment.

Results from previous studies have demonstrated that chronic opioid use following surgery has increased, with up to 10% of patients filling prescriptions more than three months after their surgery. However, according to the researchers, data involving post-operative use of opioids in those diagnosed with cancer, as well as those not diagnosed with cancer, is lacking. There is also limited data in terms of chronic opioid use patterns regarding benzodiazepine and non-benzodiazepine sedative/hypnotic use following mastectomy and reconstructive surgery.

“Despite the high rates of psychiatric disorders in the cancer population, there is little research into the rates of persistent sedative/hypnotic use in these cases,” Cogan, a fellow in hematology/oncology at NewYork-Presbyterian/Columbia University Irving Medical Center in New York, said during a press briefing.

To determine predictors of developing new persistent controlled substance use after surgery, researchers aimed to assess rates of new persistent controlled substance use after mastectomy with reconstructive surgery.

Using a health care claims database, researchers evaluated women over the age of 18 who underwent mastectomy plus reconstruction between 2008 and 2017.

Opioid and sedative-hypnotic drug prescriptions were identified across three time periods:

• pre-operative (365 days to 31 days prior to surgery; period 1);
• peri-operative (31 days prior to 90 days after their surgery; period 2), and
• post-operative (90 days to 365 days after surgery; period 3).

Patients who filled at least one prescription for controlled substances during period 1 were excluded from the study analysis. Those who did not use controlled substances during period 1 but filled at least one prescription in period 2 and at least two prescriptions in period 3 were considered new chronic users and were compared to the other non-chronic users.

The researchers conducted a separate multivariable logistic regression analysis, a method to look at two or more possible discrete outcomes, to evaluate demographic and clinical factors associated with risk of chronic use for each drug category, including age, insurance, region, breast cancer diagnosis, chemotherapy treatment, radiation treatment, prior mental health diagnosis, and prior substance use diagnosis.

In total, the researchers identified 25,270 women who were opioid-naïve and 27,651 who were sedative-hypnotic naïve.

Within each group, 13.1% of opioid-naïve patients became new chronic users and 6.6% of those in the sedative-hypnotic naïve group became new persistent users.

Patients who had never filled or received their prescriptions following surgery were then removed from the study. In turn, rates for opioid-naïve (18,931 patients) and sedative-hypnotic naïve (10,781 patients) individuals rose to 17.5% and 17.0%, respectively.

Age under 60 years, Medicaid insurance, breast cancer diagnosis, chemotherapy treatment, mental health and substance use diagnoses were all associated with higher rates of opioid use.

Moreover, the researchers found that a patient’s risk for becoming a new persistent user increased with the number of risk factors identified. For example, those with five risk factors (age, Medicaid, Southern region, breast cancer diagnosis, and chemotherapy/radiation treatment), were at a 19% increased risk of becoming a new persistent user of opioids and 10.5% increased risk of becoming a new persistent user of sedatives/hypnotics.

Commenting on the study, former AACR president Dr. Carlos Arteaga, of Southwestern Medical Center, noted that a lot of this information is known, but not all of it. “I wonder if you can tell us which are the types of patients that we might not be paying attention to, that this study is telling you to be particularly aware of for this risk of substance abuse?”

In response, Cogan explained that the risk factors found in the study spark particular attention for certain patients. “It raises the issue that, as a provider, when you’re seeing patients in follow-up, this is something you might want to explicitly ask about, and not assume that the post-operative opioids were taken and disposed of after,” he said. “Ask the patient, ‘Are you still taking opioids? Are you still taking your Ambien?’ If someone is still taking it, that’s something to diligently follow up about and make sure it’s disposed of. Or if someone is still taking it, refer them to the right services to raise a flag across the board as something we should routinely pay attention to post-operatively.”

A version of this story appeared on OncLive® as “Women Who Undergo Mastectomy with Reconstruction At Higher Risk for Chronic Controlled Substance Use.”

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