Opioids After Surgery in the United States Versus the Rest of the World

The International Patterns of Opioid Prescribing (iPOP) Multicenter Study

Haytham M. A. Kaafarani, MD, MPH; Kelsey Han, BSc; Mohamad El Moheb, MD; Napaporn Kongkaewpaisan, MD; Zhenyi Jia, MD; Majed W. El Hechi, MD; Suzanne van Wijck, MD; Kerry Breen, BSc; Ahmed Eid, MD; Gabriel Rodriguez, MD; Manasnun Kongwibulwut, MD; Ask T. Nordestgaard, MD; Joseph V. Sakran, MD, MPA, MPH; Hiba Ezzeddine, MD; Bellal Joseph, MD; Mohammad Hamidi, MD; Camilo Ortega, MD; Sonia Lopez Flores, MD; Bernardo J. Gutierrez-Sougarret, MD; Huanlong Qin, MD; Jun Yang, MD; Renyuan Gao, MD; Zhiguo Wang, MD; Zhiguang Gao, MD; Supparerk Prichayudh, MD; Said Durmaz, MD; Gwendolyn van der Wilden, MD, PhD; Stephanie Santin, MD; Marcelo A. F. Ribeiro Jr., MD, MSc, PhD; Napakadol Noppakunsomboom, MD; Ramzi Alami, MD; Lara El-Jamal, BS; Dana Naamani, BS; George Velmahos, MD, PhD; Keith D. Lillemoe, MD


Annals of Surgery. 2020;272(6):879-886. 

In This Article

Abstract and Introduction


Objective: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world.

Summary of Background Data: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic.

Methods: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients.

Results: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0–135) and 150 (0–1680) mg for US versus 0 (0–50) and 0 (0–600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ± 13.9 in US and 183.5 ± 133.7 mg versus 0.8 ± 3.9 and 4.6 ± 27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001).

Conclusions: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.


The United States (US) is in the midst of an unprecedented opioid epidemic. In 2016, drug overdoses (mostly opioids) resulted in 65,000 deaths, a number much higher than that caused by human immunodeficiency disease in 1995, at the peak of that epidemic.[1] The etiology of the opioid epidemic that commenced 2 decades ago is multifactorial and includes misleading marketing strategies by a few pharmaceutical companies that advocated for opioids as a risk-free optimal solution to pain, and a concomitant recognition by the medical and healthcare community of the importance of adequately treating patient pain. In 2001, the Joint Commission on the Accreditation of Healthcare Organizations launched an initiative to improve patient pain management.[2] Numerous studies at that time demonstrated that analgesic prescriptions were under-prescribed owing to a myriad of factors such as implicit physician biases, patient language barriers, and diverging provider beliefs regarding the necessity of analgesia.[3–5] The consequences of inadequate management of patient pain included lost productivity, increased hospitalizations, and lower quality of life.[6–8] In an effort to address this problem, the American Pain Society launched the "pain as the fifth vital sign" campaign which reinforced a societal expectation of near zero pain and contributed to healthcare providers shifting towards more aggressive pain management strategies, mostly through opioids.[9,10] Opioid prescriptions started gradually increasing since 1999, reaching 72.4 to 81.2 prescriptions per 100 persons in the US and 782 oral morphine milligram equivalents (OMEs) per capita in 2010.[9–11] The incidence of substance use disorder from prescription opioids similarly increased and its cost is currently estimated at $78 billion annually.[12] The US opioid-related death toll also increased, totaling more than 33 thousand people in 2015.[13]

Multiple studies, including qualitative interviews among individuals with opioid use disorder, suggest that diversion of unused opioid pills prescribed to patients with acute or chronic pain contributes significantly to the opioid epidemic.[14] In fact, patients are often prescribed an excessive amount of opioids. Up to 92% report not needing all the opioids prescribed postoperatively, and 77% report that their unused opioid pills were not securely stored or appropriately discarded. Hence, many of these pills are subsequently diverted (ie, stolen, sold, or given away) to the community at large.[15–18]

Surgeons alone are responsible for more than 10% of all opioids prescribed in the United States.[19] Recent studies have demonstrated a wide variation in the patterns of opioid use after most surgical procedures, even within institutions and among similar patient populations.[20–22] Despite efforts to describe the differences in opioid prescription across nations, current evidence is restricted to data derived from high-income countries.[23–25] Little data exists that compares the patterns of postoperative opioid prescribing across geographically and economically diverse areas of the world. With the US accounting for less than 5% of the world's population but consuming more than 80% of its opioids,[26] we sought to assess the patterns of post-discharge opioid prescription for the same surgical procedures performed in multiple institutions across 4 continents, with a specific focus on comparing the US to the rest of the world. We hypothesized that the amount of opioid prescribed after surgery in oral morphine equivalents and number of pills is higher in the US compared to the rest of the world.