Gabapentinoid, Opioid Prescriptions Rose in Older Patients After Surgery

Both gabapentinoid and opioid prescribing rose among post-surgical older adults, serial cross-sectional data showed.

Across nearly 500,000 Medicare recipients, the rate of new postoperative gabapentinoid prescribing increased from 2.3% in 2014 to 5.2% in 2018 (P<0.001), according to Tasce Bongiovanni, MD, MPP, of the University of California San Francisco, and co-authors.

Opioid prescribing rose during the same period, from 56% to 59% (P<0.001), while concomitant prescribing nearly tripled, jumping from 1.6% in 2014 to 4.1% in 2018 (P<0.001), they noted in JAMA Network Open.

"The use of gabapentinoid as opioid sparing does not appear to spare the proportion of patients receiving postoperative prescriptions for opioids from a surgical procedure, which is concerning for a medication that has its own inherent risks, especially when used concomitantly with opioids," Bongiovanni and colleagues observed.

"While there was variation between procedure types, almost all procedures saw an increase in both gabapentinoid and opioid prescribing," they added.

Gabapentinoids -- gabapentin (Neurontin) and pregabalin (Lyrica) -- are approved for seizures and other limited indications, but are widely prescribed off-label for pain. A recent meta-analysis found that gabapentinoids were associated with a lower postoperative pain intensity, but the effect was not clinically significant.

Common side effects of gabapentinoids include drowsiness, dizziness, blurry or double vision, and difficulty with coordination and concentration. In 2019, the FDA warned about serious breathing problems that may occur in patients using gabapentin or pregabalin who have respiratory risk factors. These factors include taking opioids or other drugs that depress the central nervous system, conditions like chronic obstructive pulmonary disease that reduce lung function, and older age.

Bongiovanni and co-authors used Medicare data to assess prescribing trends from January 2013 through December 2018, studying 494,922 gabapentinoid-naive patients ages 66 or older who had one of 14 common non-cataract surgical procedures.

The researchers defined postoperative prescribing as a prescription filled from 7 days before a procedure to 7 days after discharge from surgery. Patients discharged to skilled nursing facilities were excluded from the study.

Mean age of patients was 73.7. More than half (53.9%) were women. Most patients (86.0%) were white; 5.1% were Hispanic, and 4.9% were Black.

A total of 18,095 patients (3.7%) received a new gabapentinoid prescription postoperatively. Variation in gabapentin prescription patterns by race and ethnicity was minimal.

However, gabapentin prescribing did vary by procedure type. While initial inguinal hernia repair comprised 4.9% of total surgeries, for example, it made up only 0.9% of the new gabapentinoid prescription cohort. The most common procedures among people who received new gabapentinoid prescriptions were total knee arthroplasty (6.0%), total hip arthroplasty (5.9%), lumbar laminotomy or lumbar laminectomy (4.6%), and laparoscopic cholecystectomy (4.3%).

Opioid prescriptions rose during the 5-year study period, but mean oral morphine equivalents (OMEs) fluctuated. Mean OMEs were 436 in 2014, 471 in 2015, and 379 in 2018 (P<0.01). An OME of 436 is equivalent to 58 tablets of oxycodone (5 mg each), while an OME of 379 equals 51 tablets.

"The increase in the proportion of opioid prescribing over the same period persisted despite the increased use of gabapentinoids, medication meant to be opioid sparing," Bongiovanni and co-authors pointed out. "The increase in opioid prescribing may be balanced by the fact that OME per patient decreased; however, that decrease was only the equivalent of seven 5-mg tablets of oxycodone."

The study had several limitations, the researchers acknowledged. It used Medicare Part D data, which did not capture patients who received their medication supply from the hospital pharmacy. The authors also excluded patients with Medicare Advantage plans.

"Due to availability of Medicare data, our analysis ended in 2018, so we were unable to assess whether there had been further changes in more recent years, especially given newer data on the lack of efficacy of gabapentinoids," Bongiovanni and co-authors noted. "It is possible that although gabapentinoid prescribing was rising, it is now decreasing."

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