The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use

Charles Katzman, BS; Emily C. Harker, BS; Rizwan Ahmed, BS; Charles A. Keilin, BS; Joceline V. Vu, MD; David C. Cron, MD, MS; Vidhya Gunaseelan, MS, MHA; Yen-Ling Lai, MS, MPH; Chad M. Brummett, MD; Michael J. Englesbe, MD; Jennifer F. Waljee, MD, MPH


Annals of Surgery. 2021;274(5):e410-e416. 

In This Article

Abstract and Introduction


Objective: To determine the effect of nonchronic, periodic preoperative opioid use on prolonged opioid fills after surgery.

Background: Nonchronic, periodic opioid use is common, but its effect on prolonged postoperative opioid fills is not well understood. We hypothesize greater periodic opioid use before surgery is correlated with persistent postoperative use.

Methods: We used a national private insurance claims database, Optum's de-identifed Clinformatics Data Mart Database, to identify adults undergoing general, gynecologic, and urologic surgical procedures between 2008 and 2015 (N = 191,043). We described patterns of opioid fills based on dose, recency, duration, and continuity to categorize preoperative opioid exposure. Patients with chronic use were excluded. Our primary outcome was persistent postoperative use, defined as filling an opioid prescription between 91- and 180-days post-discharge. The association between preoperative opioid use and persistent use was determined using multivariable logistic regression, controlling for clinical covariates.

Results: In the year before surgery, 41% of patients had nonchronic, periodic opioid fills. Compared with other risk factors, patterns of preoperative fills were most strongly correlated with persistent postoperative opioid use. Patients with recent intermittent use were significantly more likely to have prolonged fills after surgery compared with opioid-naïve patients [minimal use: odds ratio (OR): 2.0, 95% confidence interval (CI) 1.89–2.03; remote intermittent: OR 4.7, 95% CI 4.46–4.93; recent intermittent: OR 12.2, 95% CI 11.49–12.90].

Conclusions: Patients with nonchronic, periodic opioid use before surgery are vulnerable to persistent postoperative opioid use. Identifying opioid use before surgery is a critical opportunity to optimize care after surgery.


The United States is among the highest consumers of opioid medications in the world. Opioid use is common, with more than 1 in 3 adults (38%) reporting use of an opioid medication in the past year.[1,2] The contribution of the healthcare system to the opioid epidemic is well-described. Opioid prescribing quadrupled over the first decade of this century, and excessive opioid prescribing is prevalent across specialties,[3,4] particularly after surgical care.[5,6] Moreover, roughly 6% of opioid-naive adults and children undergoing surgery continue to fill opioids for months after surgical care, beyond the time frame in which acute pain is expected to resolve.[7,8] Fortunately, growing recognition of opioid-related morbidity and mortality has motivated a significant reduction in surgical opioid prescribing in 2017 and 2018.[9] However, despite these declines, opioid use in the U.S. population remains prevalent.[9,10]

Chronic opioid use before surgery is associated with increased postoperative pain[11] and poorer surgical outcomes, including increased complications, longer lengths of stay, and higher readmission rates. Chronic opioid use before surgery is also correlated with higher healthcare utilization and cost.[12,13] Moreover, preoperative opioid exposure is correlated with medication tolerance, hyperalgesia, and dependence,[14,15] and patients on opioid therapy are at increased risk for poorer pain control, a greater need for refills, and the conversion to new chronic use.[16] To date; however, the majority of studies have compared outcomes between patients with chronic opioid use and opioid-naïve patients, and outcomes for patients with periodic use that may not meet criteria for chronic use have not been well described.[17–19] Given that roughly 40% of patients presenting for surgical care have filled opioid prescriptions in the year before surgery, defining the interplay between nonchronic opioid exposure and outcomes could identify opportunities to improve perioperative care.[16]

The risk of new persistent opioid use after surgery has been well defined for opioid-naïve individuals across a variety of procedures,[7,20] but the development of prolonged use among patients with varying degrees of periodic preoperative exposure is unknown. Previous work has identified 6 different patterns of preoperative use based on patients' dose, recency, duration, and continuity.[17] In this context, we sought to describe the correlation between periodic opioid use and prolonged postoperative fills. We hypothesized that more recent preoperative exposure to opioids would be associated with higher prevalence of persistent postoperative opioid use compared with opioid naïve patients.