Association of Preoperative Depression and Anxiety With Long-term Opioid Use After Hysterectomy for Benign Indications

Abstract

Objective: To assess whether preoperative depression or anxiety is associated with increased risk of long-term, postoperative opioid use after hysterectomy among women who are opioid-naïve.

Methods: We conducted an observational cohort study of 289,233 opioid-naïve adult women (18 years or older) undergoing hysterectomy for benign indications from 2010 to 2017 using IBM MarketScan databases. Opioid use and refills in the 180 days after surgery and preoperative depression and anxiety were assessed. Secondary outcomes included 30-day incidence of emergency department visits, readmission, and 180-day incidence of opioid complications. The association of depression and anxiety were compared using inverse-probability of treatment weighted log-binomial and proportional Cox regression.

Results: Twenty-one percent of women had preoperative depression or anxiety, and 82% of the entire cohort had a perioperative opioid fill (16% before surgery, 66% after surgery). Although perioperative opioid fills were relatively similar across the two groups (risk ratio [RR] 1.07, 95% CI 1.06-1.07), women with depression or anxiety were significantly more likely to have a postoperative opioid fill at every studied time period (RRs 1.44-1.50). Differences were greater when restricted to persistent use (RRs 1.49-2.61). Although opioid complications were rare, women with depression were substantially more likely to be diagnosed with opioid dependence (hazard ratio [HR] 5.54, 95% CI 4.12-7.44), and opioid use disorder (HR 4.20, 95% CI 1.97-8.96).

Conclusion: Perioperative opioid fills are common after hysterectomy. Women with preoperative anxiety and depression are more likely to experience persistent use and opioid-related complications.

Conflict of interest statement

Financial Disclosure Erin T. Carey is a consultant for Teleflex Surgical, speaker for Med IQ, and has received money for expert witness testimony for plaintiff and defense litigation unrelated to the content of the paper. Jessica Young receives consulting fees from CERobs Consulting, LLC. This work is completely independent from any consulting activities. Michelle Y. Louie is a consultant for Hologic. The other authors did not report any potential conflicts of interest.

Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.

Figures

Figure 1.

Study timeline for privately insured women who underwent hysterectomy for benign conditions between 2010 and 2017. *Up to 8-day gaps in insurance enrollment allowed; includes prescription coverage. †Prior opioid use was defined as any opioid fill between −180 and −31 days or −1 opioid fill between −30 and −1 days (to allow for perioperative fills before surgery). ‡Earliest of: insurance disenrollment, invasive surgery, end of follow up (180 days after hysterectomy); postoperative opioid fills were assessed in time windows (15–30, 31–60, 61–90, and 91–180 days after surgery); only patients with complete follow-up during time window were included for analyses. §Emergency department (ED) visits and readmission were only assessed for 30-days after surgery or discharge. LOS, length of stay.

Figure 2.

Trends in prevalence of preoperative depression or anxiety (A), perioperative opioid use (B), and postoperative persistent opioid use at 61-90 days (C) among adult women (18–65 years of age) undergoing hysterectomy for benign conditions. The percentages in A represent the proportion of women without a preoperative diagnosis of depression or anxiety. Perioperative fills in B were stratified into before (−30 to −1 days) and after (0 to 14 days) hysterectomy. Persistent postoperative opioid use in C was defined as having at least one opioid fill during the perioperative period, 15–30 days after surgery, and 31–60 days after surgery.