Postsurgical Prescriptions for Opioid Naive Patients and Association with Overdose and Misuse: Retrospective Cohort Study

Overview

Journal BMJ

Specialty General Medicine

Date 2018 Jan 19

PMID 29343479

Citations 212

Authors

Gabriel A Brat

Denis Agniel

Andrew Beam

Brian Yorkgitis

Mark Bicket

Mark Homer

Kathe P Fox

Daniel B Knecht

Cheryl N McMahill-Walraven

Nathan Palmer

Isaac Kohane

Affiliations

Soon will be listed here.

Abstract

Objective: To quantify the effects of varying opioid prescribing patterns after surgery on dependence, overdose, or abuse in an opioid naive population.

Design: Retrospective cohort study.

Setting: Surgical claims from a linked medical and pharmacy administrative database of 37 651 619 commercially insured patients between 2008 and 2016.

Participants: 1 015 116 opioid naive patients undergoing surgery.

Main Outcome Measures: Use of oral opioids after discharge as defined by refills and total dosage and duration of use. The primary outcome was a composite of misuse identified by a diagnostic code for opioid dependence, abuse, or overdose.

Results: 568 612 (56.0%) patients received postoperative opioids, and a code for abuse was identified for 5906 patients (0.6%, 183 per 100 000 person years). Total duration of opioid use was the strongest predictor of misuse, with each refill and additional week of opioid use associated with an adjusted increase in the rate of misuse of 44.0% (95% confidence interval 40.8% to 47.2%, P<0.001), and 19.9% increase in hazard (18.5% to 21.4%, P<0.001), respectively.

Conclusions: Each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.

Citing Articles

Comparative Effectiveness of Different Opioid Regimens, in Daily Dose or Treatment Duration, Prescribed at Surgical Discharge: a Systematic Review and Meta-Analysis.

Jamshidi M, Jones C, Langford A, Patanwala A, Liu C, Harris I CNS Drugs. 2025; 39(4):345-360.

PMID: 40057907 DOI: 10.1007/s40263-025-01165-9.

Patient experience of discharge opioid analgesia and care provision following spine surgery: A mixed methods study.

Allen M, Pastor A, Leslie K, Fitzpatrick B, Hogg M, Lau H Br J Pain. 2025; :20494637251322168.

PMID: 39990194 PMC: 11840826. DOI: 10.1177/20494637251322168.

Opioid-free anesthesia in enhanced recovery after supratentorial craniotomies: a case series.

Setiadi I, Alifahna M, Halimi R, Bisri D J Med Life. 2025; 17(12):1061-1066.

PMID: 39877039 PMC: 11771829. DOI: 10.25122/jml-2024-0280.

Development of an implementation intervention to promote adoption of the COMFORT clinical practice guideline for peripartum pain management: a qualitative study.

Sharif L, Cocroft S, Smith S, Benincasa C, Peahl A, Low L Implement Sci Commun. 2025; 6(1):1.

PMID: 39748382 PMC: 11697899. DOI: 10.1186/s43058-024-00687-5.

Characterizing patterns of opioid prescribing after outpatient ventral hernia repair with mesh.

Woo K, Zheng X, Goel A, Higgins R, Iacco A, Harris T Hernia. 2024; 29(1):54.

PMID: 39724506 DOI: 10.1007/s10029-024-03247-x.

References

Lenguerrand E, Wylde V, Gooberman-Hill R, Sayers A, Brunton L, Beswick A . Trajectories of Pain and Function after Primary Hip and Knee Arthroplasty: The ADAPT Cohort Study. PLoS One. 2016; 11(2):e0149306. PMC: 4752224. DOI: 10.1371/journal.pone.0149306. View

Ladha K, Patorno E, Huybrechts K, Liu J, Rathmell J, Bateman B . Variations in the Use of Perioperative Multimodal Analgesic Therapy. Anesthesiology. 2016; 124(4):837-45. PMC: 4792695. DOI: 10.1097/ALN.0000000000001034. View

Hill M, Stucke R, McMahon M, Beeman J, Barth Jr R . An Educational Intervention Decreases Opioid Prescribing After General Surgical Operations. Ann Surg. 2017; 267(3):468-472. DOI: 10.1097/SLA.0000000000002198. View

Wunsch H, Wijeysundera D, Passarella M, Neuman M . Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012. JAMA. 2016; 315(15):1654-7. PMC: 4837043. DOI: 10.1001/jama.2016.0130. View

Paulozzi L, Strickler G, Kreiner P, Koris C . Controlled Substance Prescribing Patterns--Prescription Behavior Surveillance System, Eight States, 2013. MMWR Surveill Summ. 2015; 64(9):1-14. DOI: 10.15585/mmwr.ss6409a1. View

Ciesielski T, Iyengar R, Bothra A, Tomala D, Cislo G, Gage B . A Tool to Assess Risk of De Novo Opioid Abuse or Dependence. Am J Med. 2016; 129(7):699-705.e4. PMC: 5076552. DOI: 10.1016/j.amjmed.2016.02.014. View

Deyo R, Hallvik S, Hildebran C, Marino M, Dexter E, Irvine J . Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study. J Gen Intern Med. 2016; 32(1):21-27. PMC: 5215151. DOI: 10.1007/s11606-016-3810-3. View

Strassels S, Chen C, Carr D . Postoperative analgesia: economics, resource use, and patient satisfaction in an urban teaching hospital. Anesth Analg. 2002; 94(1):130-7, table of contents. DOI: 10.1097/00000539-200201000-00025. View

Calcaterra S, Yamashita T, Min S, Keniston A, Frank J, Binswanger I . Opioid Prescribing at Hospital Discharge Contributes to Chronic Opioid Use. J Gen Intern Med. 2015; 31(5):478-85. PMC: 4835366. DOI: 10.1007/s11606-015-3539-4. View

10.

Frieden T, Houry D . Reducing the Risks of Relief--The CDC Opioid-Prescribing Guideline. N Engl J Med. 2016; 374(16):1501-4. PMC: 4852278. DOI: 10.1056/NEJMp1515917. View

11.

Menendez M, Ring D, Bateman B . Preoperative Opioid Misuse is Associated With Increased Morbidity and Mortality After Elective Orthopaedic Surgery. Clin Orthop Relat Res. 2015; 473(7):2402-12. PMC: 4457771. DOI: 10.1007/s11999-015-4173-5. View

12.

Gomes T, Mamdani M, Dhalla I, Paterson J, Juurlink D . Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011; 171(7):686-91. DOI: 10.1001/archinternmed.2011.117. View

13.

Dasgupta N, Funk M, Proescholdbell S, Hirsch A, Ribisl K, Marshall S . Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality. Pain Med. 2015; 17(1):85-98. DOI: 10.1111/pme.12907. View

14.

Miller M, Barber C, Leatherman S, Fonda J, Hermos J, Cho K . Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015; 175(4):608-15. DOI: 10.1001/jamainternmed.2014.8071. View

15.

Jena A, Goldman D, Karaca-Mandic P . Hospital Prescribing of Opioids to Medicare Beneficiaries. JAMA Intern Med. 2016; 176(7):990-7. PMC: 4955877. DOI: 10.1001/jamainternmed.2016.2737. View

16.

Volkow N, McLellan T, Cotto J, Karithanom M, Weiss S . Characteristics of opioid prescriptions in 2009. JAMA. 2011; 305(13):1299-301. PMC: 3187622. DOI: 10.1001/jama.2011.401. View

17.

Volkow N, McLellan A . Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies. N Engl J Med. 2016; 374(13):1253-63. DOI: 10.1056/NEJMra1507771. View

18.

Wu C, Raja S . Treatment of acute postoperative pain. Lancet. 2011; 377(9784):2215-25. DOI: 10.1016/S0140-6736(11)60245-6. View

19.

Brummett C, Waljee J, Goesling J, Moser S, Lin P, Englesbe M . New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017; 152(6):e170504. PMC: 7050825. DOI: 10.1001/jamasurg.2017.0504. View

20.

Hill M, McMahon M, Stucke R, Barth Jr R . Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Ann Surg. 2016; 265(4):709-714. DOI: 10.1097/SLA.0000000000001993. View