Persistent opioid use (POU) was found to be common after cardiac implantable electronic device (CIED) procedures, and higher initial prescribed oral morphine equivalence (OME) doses increased risk for developing POU, according to a study published in Circulation.

For the retrospective cohort study, researchers sourced data from the Optum deidentified Clinformatics Data Mart, which includes information from patients with commercial and Medicare Advantage health plans in the United States. Patients (N=143,400) who underwent CIED between 2004 and 2018 and were opioid-naïve within 180 days of their procedure were assessed for POU up to 270 days.

Nearly a quarter of patients (21%) filled an opioid prescription in the preceding 5 years before their procedure, and 11% filled an opioid prescription within 14 days after their procedure.

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Over time, the proportion of patients filling an opioid prescription after CIED increased (P <.0001), but the median OME dose decreased from 150 mg in 2004 to 100 mg in 2018 (P <.0001).

POU between 30 and 180 days occurred among 12.4% of patients, and between 180 and 270 days among 7.4% of patients. Study participants with POU were older, more were women, they had a history of depression, drug abuse, and psychosis (all P <.0001).

Initial OME prescribed was nonlinearly associated with the likelihood of developing POU. Patients who received more than 135 mg OME after surgery compared with patients who received less than 135 mg OME were associated with significant risk for POU (odds ratio [OR], 1.96; P <.0001).

Patients with increased risk for POU used opioids in the 5-year period before the index procedure (adjusted OR [aOR], 1.76; 95% CI, 1.58–1.97; P <.0001), had a history of drug abuse (aOR, 1.52; 95% CI, 1.13–2.01; P =.005), preoperative use of muscle relaxants (aOR, 1.52; 95% CI, 1.18–1.95; P =.001), had rheumatic disorders (aOR, 1.33; 95% CI, 1.11–1.58; P =.001), preoperative use of benzodiazepines (aOR, 1.28; 95% CI, 1.09–1.49; P =.002), chronic pulmonary disease (aOR, 1.22; 95% CI, 1.140-1.36; P =.0002), and diabetes (aOR, 1.15; 95% CI, 1.04–1.29; P =.008).

After removing the patients with the highest risk for POU, the rate of POU within 30 to 180 days was 8.9%.

This study was limited by not including prescriptions written but not filled, filled using a different pharmacy benefit, or paid for out of pocket.

The data indicated that the rate of POU was high following CIED and has been increasing over time. An initial dose over 135 mg OMEs increased risk for POU.

“All physicians who perform and care for patients after CIED procedures, including primary care providers, should be aware of the risk of POU,” the study authors said. “It is critical that postoperative opioid prescription dose be minimized and alternative analgesic regimens such as nonopioid pain medications and peripheral nerve blocks be considered.”


Markman TM, Brown CR, Yang L, et al. Persistent opioid use after cardiac implantable electronic device procedures. Circulation. Published online November 15, 2021. doi:10.1161/CIRCULATIONAHA.121.055524