Patient Factors Associated With Opioid Consumption in the Month Following Major Surgery

Daniel B. Larach, MD, MTR, MA; Michael J. Sahara, BA; Sawsan As-Sanie, MD, MPH; Stephanie E. Moser, PhD; Andrew G. Urquhart, MD; Jules Lin, MD; Afton L. Hassett, PsyD; Joseph A. Wakeford, BS; Daniel J. Clauw, MD; Jennifer F. Waljee, MD, MPH, MS; Chad M. Brummett, MD


Annals of Surgery. 2021;273(3):507-515. 

In This Article

Abstract and Introduction


Objective: The aim of this study was to determine preoperative patient characteristics associated with postoperative outpatient opioid use and assess the frequency of postoperative opioid overprescribing.

Summary Background Data: Although characteristics associated with inpatient opioid use have been described, data regarding patient factors associated with opioid use after discharge are lacking. This hampers the development of individualized approaches to postoperative prescribing.

Methods: We included opioid-naïve patients undergoing hysterectomy, thoracic surgery, and total knee and hip arthroplasty in a single-center prospective observational cohort study. Preoperative phenotyping included self-report measures to assess pain severity, fibromyalgia survey criteria score, pain catastrophizing, depression, anxiety, functional status, fatigue, and sleep disturbance. Our primary outcome measure was self-reported total opioid use in oral morphine equivalents. We constructed multivariable linear-regression models predicting opioids consumed in the first month following surgery.

Results: We enrolled 1181 patients; 1001 had complete primary outcome data and 913 had complete phenotype data. Younger age, non-white race, lack of a college degree, higher anxiety, greater sleep disturbance, heavy alcohol use, current tobacco use, and larger initial opioid prescription size were significantly associated with increased opioid consumption. Median total oral morphine equivalents prescribed was 600 mg (equivalent to one hundred twenty 5-mg hydrocodone pills), whereas median opioid consumption was 188 mg (38 pills).

Conclusions: In this prospective cohort of opioid-naïve patients undergoing major surgery, we found a number of characteristics associated with greater opioid use in the first month after surgery. Future studies should address the use of non-opioid medications and behavioral therapies in the perioperative period for these higher risk patients.


US opioid abuse has been termed an epidemic, with 134 Americans dying on average daily.[1] Although prescribing has decreased in recent years,[2] there were still >193 billion oral morphine equivalents (OMEs) prescribed in 2016.[3] Most public health and research efforts have focused on the appropriate use of opioids in chronic pain conditions and on medication-assisted treatment for opioid abuse. However, many patients' initial opioid prescriptions come from surgical care.[4] New chronic opioid use may represent the most common complication after a wide variety of elective surgeries.[5–10] Additionally, approximately 70% of opioid pills prescribed after surgery go unused and become a source for misuse, abuse, and diversion.[11,12]

Recently, a number of states have implemented supply limits of ≤7 days for initial opioid prescriptions, including surgical prescribing.[13] Although prescribing limits have some potential benefits, such policy efforts are not necessarily patient-centered and may undertreat pain for some patients.[14] Moreover, blunt policies that are not data-driven may not resonate with surgeons (who may be fearful of poor patient satisfaction or the need for refills), and limits can also still lead to overprescribing. A more individualized approach to postoperative opioid prescribing may minimize unused opioids and the incidence of prolonged postoperative opioid use while ensuring adequate analgesia.

Previous studies have associated a number of factors with opioid use during the inpatient period, particularly psychological characteristics such as distress, anxiety, and centralized pain.[15–17] However, limited data exist regarding patient phenotypes associated with post-discharge opioid use. Furthermore, most known risk factors for opioid consumption are based on studies of single conditions or insurance claims data. Using data from a prospective registry, we designed the present study to fill this knowledge gap by assessing patient factors associated with opioid consumption in the first month following major surgery and to examine the prevalence of opioid overprescribing at a major academic medical center.