Opioid Prescribing Remains High After Cardiac Electronic Device Implantation

The proportion of patients who fill an opioid prescription following implantation of a cardiac implantable electronic device (CIED) peaked at almost one in five in 2016 and has only modestly declined through 2020, according to new data.

This trend is worrisome to researchers, who argue that electrophysiologists who perform pacemaker and implantable cardioverter-defibrillator (ICD) procedures should be more cognizant of their potential contribution to the ongoing opioid epidemic and take measures to reduce these prescriptions even further.

“We all know that prescription opioids are a significant driver of the opioid epidemic and there really has been no decrease in opioid deaths,” senior author David Frankel, MD (Hospital of the University of Pennsylvania, Philadelphia), told TCTMD. “While there have been lots of attention to limiting opioid prescriptions in the emergency room and pain clinics and settings such as that, I don't think that we as cardiac electrophysiologists really think about the opioids we prescribe as potential drivers of this opioid epidemic.”

Electrophysiologists, he continued, are traditionally zeroed in on treating arrhythmias and might not think twice about a small opioid prescription following a CIED implantation because they’re “coming from a good place. You don't want your patients to suffer after a pacemaker or defibrillator, [and] people wouldn't consider those as potential triggers for opioid addiction.”

If electrophysiologists become aware that even these small prescriptions can really start patients on a path towards addiction, I think that they will prescribe them even less frequently. David Frankel

In their research letter published last week in Circulation, Timothy M. Markman, MD (Hospital of the University of Pennsylvania), Frankel and colleagues showed that among 242,054 patients who underwent a CIED implantation between 2004 and 2020, a total of 14% filled an opioid prescription within 14 days of their procedure. This measure rose steadily from 7.4% in 2004 to a peak of 18.9% in 2016 (P < 0.0001), when the Centers for Disease Control and Prevention (CDC) issued guidelines to reduce opioid prescriptions. By 2020, 16.4% of patients were still filling these prescriptions (P < 0.0001).

Also, the mean opioid dose prescribed did not decrease significantly from 2016 to 2020 (276 to 231 mg; P = 0.2). In fact, in 2020 more than one-third of opioid prescriptions in this population remained over the 135 mg threshold researchers identified as being associated with increased risk of persistent opioid use.

These data build upon a 2021 study published by the same group in Circulation that showed that 12% of post-CIED implantation patients continue to use opioids more than 30 days after their procedures.

“The message here isn't that pacemakers are very-high-risk procedures,” Frankel said. “The message here is what we know applies to everyone else applies to us, too.”

A notable anecdotal finding, he added, was that while the initial opioid prescription in these cases is always written by the electrophysiologist, “that next prescription that's filled is almost never written by the electrophysiologist.” This could be a primary reason why electrophysiologists lack awareness of the scope of the problem, Frankel continued, because “our patients aren't coming back to us and trying to get more opioids. They're going to their primary care doctor or a pain clinic or the emergency room.”

Three Steps

He recommends that electrophysiologists in these settings take three steps to reduce their footprint on the opioid epidemic. First, they need to establish expectations for pain with their patients. “We have this approach or this mentality where any pain that a patient experiences is a bad thing, not a natural part of the healing process,” Frankel said.

Next, some intraprocedural steps operators can take to reduce potential for pain include using “long acting local anesthetics, peripheral nerve blocks, tumescent anesthesia, and meticulous surgical technique to reduce the rate of complications,” he explained.

Lastly, postprocedure, Frankel recommends using acetaminophen, ibuprofen, and even potentially gabapentin “synergistically” in order to reduce the need for opioids.

Looking at the trends seen in the study, Frankel said he was pleased to see a drop in the use following 2016, but “it's clearly still important that we continue to decrease the rate of opioid prescriptions,” he said. “If electrophysiologists become aware that even these small prescriptions can really start patients on a path towards addiction, I think that they will prescribe them even less frequently and rely more heavily on those alternative strategies.”