Key Points
Question
Which procedures account for the most opioids dispensed to adults after surgery?
Findings
In a cross-sectional analysis of claims data for more than 1 million major surgical procedures among privately and publicly insured adults, cesarean delivery accounted for the largest proportion of opioids dispensed after surgery among individuals aged 18 to 44 years. Among procedures accounting for the 5 highest proportions of opioids dispensed after surgery to individuals aged 45 to 64 years, 4 were orthopedic procedures.
Meaning
These findings suggest that the design and targeting of surgical opioid stewardship initiatives for adults should focus on the procedures that account for the greatest share of postoperative opioid prescribing.
This cross-sectional study evaluates which surgical procedures are associated with the largest proportion of opioid prescribing for postoperative pain among US adults.
Abstract
Importance
Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs.
Objective
To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States.
Design, Setting, and Participants
This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023.
Main Outcomes and Measures
The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years.
Results
Among 1 040 934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663 609 [63.7%] female patients), 457 016 (43.9%) occurred among individuals aged 18 to 44 years and 583 918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503 058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11 418 658 of 58 825 364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5 885 305 of 60 591 564 MMEs]; arthroscopy of knee, 6.5% [3 912 616 MMEs]).
Conclusions and Relevance
In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.
Introduction
Opioids are commonly prescribed in the United States after surgery, with prescription rates often far exceeding those in other countries.1,2,3 General awareness of the association between opioid prescribing and related morbidity and mortality has grown since the early 2000s after national prescribing rates quadrupled between 1999 and 2010, accompanied by a dramatic rise in opioid-related overdose deaths.4,5,6 In the context of surgical care, numerous studies have demonstrated an association between opioid prescribing for postoperative pain and opioid-related adverse events, such as persistent opioid use, misuse, and overdose.7,8,9,10,11,12 Moreover, in the absence of clear guidelines to direct prescribing for acute postoperative pain, surgical opioid prescribing has historically been marked by prescription volumes beyond typical patient need, often coupled with potentially high-risk prescribing patterns.13,14,15 To reduce the risk of these adverse events, professional societies, policymakers, and payers have implemented numerous efforts to curb excessive postoperative opioid prescribing.16,17,18
Encouragingly, a recent analysis showed that the rate of opioid dispensing among US surgeons decreased 35.6% between 2016 and 2022.19 At the same time, the average opioid prescription provided by surgeons in December 2022 involved the equivalent of 44 pills containing 5-mg hydrocodone, an average prescription size that still exceeds expected pain management requirements for many procedures.20 However, much less is known regarding the specific procedures that contribute to the overall landscape of opioids dispensed in the United States, particularly after the implementation of these widespread opioid stewardship strategies. A deeper understanding of the current landscape of opioid prescribing in the United States could identify future areas to optimize opioid prescribing while maintaining patient-centered outcomes and experience.
In this context, we conducted a national study of opioid prescribing after surgical procedures among privately and publicly insured nonelderly adults (ie, adults younger than 65 years) in 2020 to 2021. We assessed the procedures that accounted for the highest dose, frequency, and refills for postoperative opioid medication as well as those accounting for the most coprescribing with benzodiazepines, a practice associated with higher risk of opioid overdose.21,22,23 Given the resource constraints of our current health care system, this information could help direct limited resources for surgical opioid stewardship toward targets that will provide the greatest value.
Methods
Data Source
We examined health care claims obtained from the Merative MarketScan Commercial and Medicaid Multi-State Databases, which are US claims databases that include deidentified, individual-level data for 23 million privately insured and 14 million publicly insured individuals annually.24,25 The commercial database includes nonelderly (aged <65 years) individuals with employer-sponsored private insurance across the US, while the Medicaid database includes nonelderly individuals from 10 to 12 states. Due to the deidentified nature of this data, this study was deemed exempt from human participant review and requirement for informed consent by the institutional review board of the University of Michigan Medical School. This report adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies.
Study Cohort
The study cohort included both inpatient and ambulatory surgical procedures performed between December 1, 2020, and November 30, 2021, among adults aged 18 to 64 years. Qualifying procedures were obtained using 3664 Current Procedural Terminology (CPT) codes designated as major surgical procedures by the Agency for Healthcare Research and Quality’s Surgery Flags for Services and Procedures algorithm.26 The CPT codes were then aggregated by the authors into 1082 procedure types through a consensus-based approach supplemented by literature review to collapse procedures into categories of similar nature (eAppendix 1 in Supplement 1). The clinician type performing the procedure was not considered in this analysis.
We excluded any procedure performed for an individual with the following: (1) absence of continuous insurance coverage from 180 days prior through 30 days after the discharge date from surgery to ensure complete assessment of opioid fills during this period, (2) any other surgical procedure in the 30 days prior to or 30 days after the discharge date to reliably capture opioid dispensing related to the index surgical procedure rather than previous or subsequent procedures, (3) any additional hospitalization in the 30 days after the discharge date to ensure that the opioid dispensed was associated with the index surgical procedure and not an unrelated event, (4) length of stay extending more than 14 days after the procedure to control for patient clinical complexity, (5) a discharge destination other than home to ensure that all opioids filled were captured, (6) opioid prescriptions dispensed within 3 days of the discharge date that had missing or invalid dosing information (ie, days supplied ≤0, days supplied >90, quantity <1, or total opioid dosage greater than the 99th percentile as measured in oral morphine milligram equivalents [MMEs], a standardized measure of opioid amount) to ensure accurate measurement of outcomes and exclude outliers. For situations in which multiple procedures were performed on the same day or during the same episode of care (18.6% of all procedures), prescriptions were attributed to the procedure that held the greatest likelihood of involving a surgical opioid prescription as an indicator of the level of surgical intensity or postoperative pain. This was accomplished by locating all instances during the study period when the procedure in question was the only procedure performed on a given date, and then calculating the percentage of those cases associated with a dispensed opioid prescription to represent the estimated likelihood of that particular procedure involving an opioid prescription. If more than 1 procedure remained after this step, the prescription was attributed to the procedure that occurred most frequently in our sample. A single episode of care that was still associated with multiple procedures at this point was resolved by random assignment of the remaining prescriptions.
Calculation of MMEs
MMEs for each prescription were calculated by multiplying 3 components: (1) the dosage of the opioid dispensed, (2) conversion factor appropriate for each opioid type (eAppendix 4 in Supplement 2), and (3) quantity dispensed (dose × conversion factor × quantity). Dosage calculated as dosage per milliliter for liquids and dosage per micrograms for patches, films, and sprays was used in the calculation of MMEs.
Outcomes
For each procedure type, we summed the total MMEs of opioid prescriptions associated with that procedure that were dispensed on or within 3 days of discharge (dispensed opioid prescriptions). We then summed the total MMEs in dispensed opioid prescriptions across all procedure types. The primary outcome was the former quantity divided by the latter quantity, or the proportion of total MMEs attributed to each procedure type. For each procedure type, we also calculated several secondary outcomes: (1) mean MMEs per prescription, (2) proportion of all surgical opioid prescriptions accounted for by the procedure type, (3) rate of initial opioid prescription (ie, proportion of procedures with a dispensed opioid prescription), (4) proportion of all opioid prescription refills (defined as an additional opioid prescription dispensed within 4 and 30 days of discharge) accounted for by the procedure type, (5) refill rate (ie, the proportion of procedures with at least 1 refill), (6) proportion of dispensed opioid prescriptions with benzodiazepine overlap accounted for by the procedure type (regardless of whether the benzodiazepine prescription was dispensed before, on, or after the discharge date), and (7) rate of opioid-benzodiazepine overlap. When measuring opioid-benzodiazepine overlap, only benzodiazepine prescriptions dispensed before or on the same day as the opioid prescription were considered.
Statistical Analysis
Data analysis was conducted from November to December 2023. We stratified analyses among procedures for individuals aged 18 to 44 years and 45 to 64 years, based on previously defined age categories.27,28 We described the characteristics of individuals undergoing procedures, including age, sex, type of insurance, and opioid exposure status, as defined by the presence of any opioid prescription dispensed in the 180 days prior to the procedure date. Additionally, given that there might be differences in the procedures by age and sex, we further calculated outcomes for procedures stratified by both age group and sex. Descriptive statistics were used for all analyses. Descriptive statistics calculated included mean and standard deviation for MME as well as rates and proportion for all outcomes. All procedures in the study, including procedures that did not have an associated dispensed opioid prescription, were included in the calculation of descriptive statistics for all outcomes. Analyses were conducted using Stata MP version 14.2 (StataCorp). In a sensitivity analysis to account for potential differences in prescribing attributable to health care disruption due to the COVID-19 pandemic, we repeated these analyses among surgical procedures for adults between December 1, 2018, and November 30, 2019, to capture a period that preceded the pandemic.
Results
The study sample included 1 040 934 surgical episodes (eAppendix 2 in Supplement 2). Of the 1082 procedure types in the crosswalk, 892 were represented in the sample. The total number of unique patients in the entire cohort was 917 351 (eFigure in Supplement 2). Among the 1 040 934 procedures, 457 016 (43.9%) occurred among individuals aged 18 to 44 years, and 583 918 (56.1%) occurred among individuals aged 45 to 64 years, with an overall mean (SD) age of 45.5 years (13.3); 663 309 procedures (63.7%) occurred among female patients, and 798 792 (76.7%) occurred among privately insured individuals. Demographic attributes of individuals in the sample are detailed in Table 1. Overall, 503 058 of the 1 040 934 surgical episodes (48.3%) were associated with a dispensed opioid prescription. The number of unique patients with a dispensed opioid prescription was 480 757. Opioid-benzodiazepine overlap occurred in 24 404 procedures, representing 2.3% of the 1 040 934 procedures and 4.9% of the 503 058 procedures with a dispensed opioid prescription. For 118 275 procedures (11.4%), the opioid prescription was filled prior to the discharge date. This rate was 12.1% among privately insured procedures (96 289 of 798 792) and 9.1% among publicly insured procedures (21 986 of 242 142).
Table 1. Cohort Patient Demographic Characteristics.
| Characteristic | Patients, No. (%) | ||
|---|---|---|---|
| Overall (N = 1 040 934) | Commercial (n = 798 792) | Medicaid (n = 242 142) | |
| Age, mean (SD), y | 45.52 (13.29) | 47.33 (12.71) | 39.52 (13.42) |
| Age group | |||
| 18-44 y | 457 016 (43.9) | 302 823 (37.9) | 154 193 (63.7) |
| 45-64 y | 583 918 (56.1) | 495 969 (62.1) | 87 949 (36.3) |
| Sex | |||
| Male | 377 625 (36.3) | 314 433 (39.4) | 63 192 (26.1) |
| Female | 663 309 (63.7) | 484 359 (60.6) | 178 950 (73.9) |
| Preoperative opioid exposurea | |||
| Naive | 664 603 (63.8) | 555 209 (69.5) | 109 394 (45.2) |
| Exposed | 376 331 (36.2) | 243 583 (30.5) | 132 748 (54.8) |
Defined as opioid prescriptions dispensed in the 180 days prior to the discharge date.
MMEs
For each age group, Table 2 displays the surgical procedures accounting for the greatest proportions of total MMEs in dispensed opioid prescriptions. Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs (19.4% [11 418 658 of 58 825 364 MMEs]), followed by hysterectomy (6.8% [3 971 371 MMEs]) and knee arthroscopy (6.3% [3 681 759 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were orthopedic procedures (knee arthroplasty [9.7% (5 885 305 of 60 591 564 MMEs)], knee arthroscopy [6.5% (3 912 616 MMEs)], shoulder arthroscopy [6.3% (3 796 756 MMEs)], and hip arthroplasty [4.9% (2 942 017 MMEs)]). These 4 procedures collectively accounted for 27.4% of total MMEs dispensed to individuals in this age group. Within the top 10 procedures by proportion of total MMEs, laminectomy/corpectomy corresponded to the highest individual mean (SD) MME per dispensed opioid prescription in individuals aged 18 to 44 years (237.4 [381.5] MMEs per procedure). Knee arthroplasty corresponded to the highest mean (SD) MME per prescription in individuals aged 45 to 64 years (254.6 [442.1] MMEs).
Table 2. Surgical Procedures Accounting for the Greatest Proportion of MMEs in Dispensed Opioid Prescriptions.
| Procedure name | No. of procedures | Total MMEs | MMEs per procedure, mean (SD)a | Proportion of all total MMEs, %b |
|---|---|---|---|---|
| Patients aged 18-44 y | ||||
| Cesarean delivery | 95 720 | 11 418 658 | 119.3 (234.4) | 19.4 |
| Hysterectomy: laparoscopic or vaginal | 29 464 | 3 971 371 | 134.8 (272.4) | 6.8 |
| Arthroscopy of knee | 20 486 | 3 681 759 | 179.7 (398.3) | 6.3 |
| Cholecystectomy: laparoscopic | 24 523 | 3 460 305 | 141.1 (276.9) | 5.9 |
| Tonsillectomy and/or adenoidectomy | 10 045 | 2 306 590 | 229.6 (495.1) | 3.9 |
| Open treatment of fracture, lower extremity | 7679 | 1 721 621 | 224.2 (465.3) | 2.9 |
| Rhinoplasty | 12 851 | 1 588 476 | 123.6 (295.7) | 2.7 |
| Arthroscopy of shoulder | 7870 | 1 513 417 | 192.3 (379.4) | 2.6 |
| Laminectomy/corpectomy | 6030 | 1 431 273 | 237.4 (381.5) | 2.4 |
| Open treatment of fracture, upper extremity | 7099 | 1 365 538 | 192.4 (418.0) | 2.3 |
| Patients aged 45-64 y | ||||
| Arthroplasty of knee | 23 116 | 5 885 305 | 254.6 (442.1) | 9.7 |
| Arthroscopy of knee | 29 303 | 3 912 616 | 133.5 (271.5) | 6.5 |
| Arthroscopy of shoulder | 19 511 | 3 796 756 | 194.6 (366.1) | 6.3 |
| Laminectomy/corpectomy | 12 979 | 3 069 599 | 236.5 (372.7) | 5.1 |
| Arthroplasty of hip | 13 217 | 2 942 017 | 222.6 (405.5) | 4.9 |
| Cholecystectomy: laparoscopic | 18 639 | 2 242 399 | 120.3 (234.2) | 3.7 |
| Arthrodesis of spine | 8656 | 2 084 924 | 240.9 (386.1) | 3.4 |
| Hysterectomy: laparoscopic or vaginal | 17 610 | 2 067 291 | 117.4 (238.4) | 3.4 |
| Nerve decompression | 15 192 | 1 563 312 | 102.9 (254.4) | 2.6 |
| Biceps tenodesis or reconstruction | 6050 | 1 264 995 | 209.1 (401.3) | 2.1 |
Abbreviation: MME, morphine milligram equivalent.
Mean MMEs were calculated across all procedures in the sample regardless of whether the procedure was associated with a dispensed opioid prescription, with MME being counted as 0 for those procedures without an opioid prescription.
The total MMEs across all procedures was 58 825 364 among patients aged 18 to 44 years and 60 591 564 among those aged 45 to 64 years.
Dispensed Opioid Prescriptions
For each age group, Table 3 displays the surgical procedures that accounted for the greatest proportion of dispensed opioid prescriptions in the sample. The highest proportion of surgical opioid prescriptions dispensed among individuals aged 18 to 44 years was cesarean delivery, representing 22.2% of all prescriptions (56 353 of 253 403 prescriptions), nearly 3 times the number of the second-highest procedure (hysterectomy, 8.0% [20 348 prescriptions]). Among the top 10 procedures accounting for the most dispensed opioid prescriptions among individuals aged 18 to 44 years, laparoscopic cholecystectomy had the highest individual rate of dispensed opioid prescriptions at 75.2% (18 449 of 24 523 procedures). Similar to trends observed for dispensed MMEs, 3 of the top 5 procedures for dispensed opioid prescriptions among individuals aged 45 to 64 years were orthopedic procedures (knee arthroplasty [5.4% (13 552 of 249 655 prescriptions)], knee arthroscopy [6.7% (16 829 prescriptions)], and shoulder arthroscopy [4.5% (11 291 prescriptions)]).
Table 3. Surgical Procedures Accounting for the Greatest Proportion of Surgical Opioid Prescriptions Dispensed.
| Procedure name | Total procedures, No. | Procedures with an opioid prescription, No. | Opioid dispensing rate, % | Proportion of all surgical opioid prescriptions dispensed, %a |
|---|---|---|---|---|
| Patients aged 18-44 y | ||||
| Cesarean delivery | 95 720 | 56 353 | 58.9 | 22.2 |
| Hysterectomy: laparoscopic or vaginal | 29 464 | 20 348 | 69.1 | 8.0 |
| Cholecystectomy: laparoscopic | 24 523 | 18 449 | 75.2 | 7.3 |
| Arthroscopy of knee | 20 486 | 11 789 | 57.5 | 4.7 |
| Appendectomy: laparoscopic | 10 787 | 7356 | 68.2 | 2.9 |
| Rhinoplasty | 12 851 | 7348 | 57.2 | 2.9 |
| Tonsillectomy and/or adenoidectomy | 10 045 | 6428 | 64.0 | 2.5 |
| Nerve decompression | 7530 | 4671 | 62.0 | 1.8 |
| Open treatment of fracture, lower extremity | 7679 | 4567 | 59.5 | 1.8 |
| Arthroscopy of shoulder | 7870 | 4487 | 57.0 | 1.8 |
| Patients aged 45-64 y | ||||
| Arthroscopy of knee | 29 303 | 16 829 | 57.4 | 6.7 |
| Cholecystectomy: laparoscopic | 18 639 | 13 684 | 73.4 | 5.5 |
| Arthroplasty of knee | 23 116 | 13 552 | 58.6 | 5.4 |
| Hysterectomy: laparoscopic or vaginal | 17 610 | 11 640 | 66.1 | 4.7 |
| Arthroscopy of shoulder | 19 511 | 11 291 | 57.9 | 4.5 |
| Nerve decompression | 15 192 | 8439 | 55.5 | 3.4 |
| Laminectomy/corpectomy | 12 979 | 8195 | 63.1 | 3.3 |
| Arthroplasty of hip | 13 217 | 7700 | 58.3 | 3.1 |
| Hernia repair, abdominal: open | 8258 | 5984 | 72.5 | 2.4 |
| Hernia repair, inguinal/femoral: laparoscopic | 7210 | 5437 | 75.4 | 2.2 |
The total number of procedures with an opioid prescription dispensed was 253 403 among patients aged 18 to 44 years and 249 655 among those aged 45 to 64 years.
Opioid Prescription Refills
For each age group, Table 4 displays the surgical procedures that accounted for the greatest proportion of opioid refills in the sample. Among individuals aged 18 to 44 years, the top 3 procedures that accounted for the greatest proportion of refills were cesarean birth (7.7% of all refills [3439 of 44 814 refills]), knee arthroscopy (6.3% [2816]), and hysterectomy (5.5% [2487]). Despite high initial fill rates, laparoscopic cholecystectomy represented only a 2.9% proportion of all refills among individuals aged 18 to 44 years. Among individuals aged 45 to 64 years, 8 of the top 10 procedures by proportion of refills were orthopedic operations, with knee arthroplasty accounting for both the highest proportion of refills (20.7% [17 059 of 82 404]) and the highest individual refill rate (35.7% [8255 of 23 116]).
Table 4. Surgical Procedures Accounting for the Greatest Proportion of Opioid Prescription Refills.
| Procedure name | Procedures, No. | Procedures with refills, No. | Refill rate, % | Refills, No. | Proportion of all refills, %a |
|---|---|---|---|---|---|
| Patients aged 18-44 y | |||||
| Cesarean delivery | 95 720 | 2961 | 3.1 | 3439 | 7.7 |
| Arthroscopy of knee | 20 486 | 1817 | 8.9 | 2816 | 6.3 |
| Hysterectomy: laparoscopic or vaginal | 29 464 | 1838 | 6.2 | 2487 | 5.5 |
| Open treatment of fracture, lower extremity | 7679 | 1386 | 18.0 | 2340 | 5.2 |
| Laminectomy/corpectomy | 6030 | 1179 | 19.6 | 2114 | 4.7 |
| Tonsillectomy and/or adenoidectomy | 10 045 | 1615 | 16.1 | 1859 | 4.1 |
| Arthroscopy of shoulder | 7870 | 1027 | 13.0 | 1673 | 3.7 |
| Open treatment of fracture, upper extremity | 7099 | 804 | 11.3 | 1363 | 3.0 |
| Cholecystectomy: laparoscopic | 24 523 | 1063 | 4.3 | 1317 | 2.9 |
| Arthrodesis of spine | 2674 | 718 | 26.9 | 1317 | 2.9 |
| Patients aged 45-64 y | |||||
| Arthroplasty of knee | 23 116 | 8255 | 35.7 | 17 059 | 20.7 |
| Laminectomy/corpectomy | 12 979 | 3114 | 24.0 | 5428 | 6.6 |
| Arthroscopy of shoulder | 19 511 | 3317 | 17.0 | 5201 | 6.3 |
| Arthroplasty of hip | 13 217 | 2786 | 21.1 | 4915 | 6.0 |
| Arthrodesis of spine | 8656 | 2277 | 26.3 | 3975 | 4.8 |
| Arthroscopy of knee | 29 303 | 2191 | 7.5 | 3303 | 4.0 |
| Open treatment of fracture, lower extremity | 6519 | 1233 | 18.9 | 2085 | 2.5 |
| Nerve decompression | 15 192 | 1066 | 7.0 | 1650 | 2.0 |
| Open treatment of fracture, upper extremity | 6400 | 883 | 13.8 | 1504 | 1.8 |
| Biceps tenodesis or reconstruction | 6050 | 908 | 15.0 | 1453 | 1.8 |
The total number of refills was 44 814 among patients aged 18 to 44 years and 82 404 among those aged 45 to 64 years.
Opioid-Benzodiazepine Prescription Overlap
For each age group, Table 5 displays the surgical procedures that accounted for the 10 greatest proportions of procedures with opioid-benzodiazepine overlap in the sample. Among individuals aged 18 to 44 years, hysterectomy—one of the most common procedures in this age group—accounted for the greatest proportion of procedures with opioid-benzodiazepine overlap (9.7% [845 of 8688]), although the individual rate of overlap after hysterectomy was only 2.9% (845 of 29 464 procedures). Laminectomy/corpectomy accounted for the greatest proportion of procedures with opioid-benzodiazepine overlap among individuals aged 45 to 64 years (6.9% [1091 of 15 716]). Among the top 10 procedures for proportion of opioid-benzodiazepine overlap across both age groups, the highest rates of overlap occurred following spine arthrodesis (11.1% among individuals aged 18-44 years [296 of 2674]; 8.8% among individuals aged 45-64 years [762 of 8656]). A complete list of outcomes for all procedure types is detailed in eAppendix 2 in Supplement 2.
Table 5. Surgical Procedures Accounting for the Greatest Proportion of Procedures With Opioid-Benzodiazepine Overlap.
| Procedure name | Procedures, No. | Procedures with opioid-benzodiazepine overlap, No. | Opioid-benzodiazepine overlap rate, % | Proportion of all procedures with opioid-benzodiazepine overlap, %a |
|---|---|---|---|---|
| Patients aged 18-44 y | ||||
| Hysterectomy: laparoscopic or vaginal | 29 464 | 845 | 2.9 | 9.7 |
| Cholecystectomy: laparoscopic | 24 523 | 594 | 2.4 | 6.8 |
| Laminectomy/corpectomy | 6030 | 420 | 7.0 | 4.8 |
| Arthroscopy of knee | 20 486 | 344 | 1.7 | 4.0 |
| Arthrodesis of spine | 2674 | 296 | 11.1 | 3.4 |
| Cesarean delivery | 95 720 | 249 | 0.3 | 2.9 |
| Rhinoplasty | 12 851 | 249 | 1.9 | 2.9 |
| Nerve decompression | 7530 | 247 | 3.3 | 2.8 |
| Arthroscopy of shoulder | 7870 | 193 | 2.5 | 2.2 |
| Gastric bypass | 7846 | 170 | 2.2 | 2.0 |
| Patients aged 45-64 y | ||||
| Laminectomy/corpectomy | 12 979 | 1091 | 8.4 | 6.9 |
| Arthroplasty of knee | 23 116 | 886 | 3.8 | 5.6 |
| Arthrodesis of spine | 8656 | 762 | 8.8 | 4.8 |
| Arthroscopy of knee | 29 303 | 755 | 2.6 | 4.8 |
| Arthroscopy of shoulder | 19 511 | 668 | 3.4 | 4.3 |
| Cholecystectomy: laparoscopic | 18 639 | 663 | 3.6 | 4.2 |
| Hysterectomy: laparoscopic or vaginal | 17 610 | 551 | 3.1 | 3.5 |
| Nerve decompression | 15 192 | 467 | 3.1 | 3.0 |
| Arthroplasty of hip | 13 217 | 430 | 3.3 | 2.7 |
| Biopsy or excision of lymph node(s) | 7479 | 380 | 5.1 | 2.4 |
The total number of procedures with opioid-benzodiazepine overlap was 8688 among patients aged 18 to 44 years and 15 716 among those aged 45 to 64 years, respectively.
Analysis by Sex
When further stratified by sex, the 3 procedures accounting for the highest proportion of MMEs among male patients aged 18 to 44 years were orthopedic procedures (knee arthroscopy, shoulder arthroscopy, and open treatment of upper extremity). Laparoscopic cholecystectomy was seventh highest for male patients aged 18 to 44 years and third highest for females aged 18 to 44 years, after cesarean delivery and hysterectomy. See eAppendix 3 in Supplement 1 for all outcomes stratified by both age group and sex.
Sensitivity Analysis
Results from the sensitivity analysis were similar to the primary analysis. The overall number of procedures varied by only 7.5%, with 1 125 749 procedures in the sensitivity analysis vs the 1 040 934 procedures in the main analysis. Among individuals aged 18 to 44 years, the top 5 procedures accounting for the highest shares of total MMEs were the same in the main and sensitivity analyses (cesarean delivery, hysterectomy, knee arthroscopy, cholecystectomy, and tonsillectomy and/or adenoidectomy), with only 1 change in placement between the third- and fourth-highest procedures. For individuals aged 45 to 64 years, the top 3 procedures were the same and in the same placements (knee arthroplasty, knee arthroscopy, and shoulder arthroscopy).
Discussion
Acute pain after surgical procedures is expected, and opioids are highly effective analgesics in this context. Guidelines are needed to best align opioid prescribing with patient need and require data centered on patient-reported outcomes and experience to understand the appropriate amount of opioids for management of postoperative pain.29 While fundamental to developing guidelines, such data are resource intensive to collect and lacking for many procedures. Therefore, understanding which procedures account for the greatest proportion of opioid prescribing can direct public health initiatives to optimize opioid stewardship to those areas of greatest value.
In this cross-sectional analysis of surgical procedures for privately and publicly insured nonelderly adults from December 2020 through November 2021, nearly half of all procedures were associated with a dispensed postoperative opioid prescription. Among procedures for individuals aged 18 to 44 years, 7 procedures were responsible for more than half of all dispensed opioid prescriptions, with cesarean delivery and hysterectomy accounting for high proportions of MMEs and opioids dispensed after surgery. For individuals aged 45 to 64 years, orthopedic procedures accounted for the greatest share of postoperative opioid dispensing. Overall, procedures that are among the most commonly performed accounted for the highest proportions of opioid prescribing and amount prescribed. These findings highlight the need to design surgical opioid stewardship initiatives in consideration with the frequency at which procedures occur, particularly by age group.
Our finding of the high rate of opioid prescribing following cesarean delivery largely aligns with prior studies, which often show prescribing rates exceeding 90%.30,31 The incidence of cesarean deliveries has increased dramatically in the last 2 decades and currently accounts for more than one-third of all births in the United States, which likely underlies the large proportion of opioid prescriptions that these procedures account for in postoperative opioid prescribing.32,33 Similar to other procedures, excessive prescribing is common following cesarean delivery and associated with important risks, including overdose and new persistent opioid use.31,34,35,36,37 The American College of Obstetricians and Gynecologists currently recommends a stepwise, multimodal approach to pain management with low-dose, short-acting opioids used only when necessary.38 Such opioid-sparing pain management strategies have been implemented in recent years with promising early results related to opioid consumption associated with lower prescribing volumes and increased successful utilization of nonopioid pain management strategies.39,40,41 It is critical to include obstetrician-gynecologists and other obstetric care professionals in the conversations surrounding post–cesarean delivery opioid use as well as the patients themselves. Going forward, a deeper understanding of the patient factors that drive opioid use after obstetric procedures could allow clinicians to tailor prescriptions to meet patient need and engage in shared decision-making regarding patient preferences for postpartum pain management.
Our findings also suggest that current strategies to promote clinical practice guidelines that align opioid prescribing with patient need may have slow uptake. For example, we observed that for individuals aged 18 to 44 years, opioids were dispensed following laparoscopic cholecystectomy in three-quarters of cases, even though opioid alternatives may be equally effective for postoperative pain management.42,43,44,45 Laparoscopic cholecystectomy is one of the most common procedures performed and was one of the early targets of opioid stewardship initiatives to develop prescribing guidelines informed by data on patient-reported opioid consumption.46 Moreover, studies have demonstrated that postoperative recovery avoiding opioids altogether is feasible and acceptable to patients.42 Nonetheless, findings show that prescribing rates remain high following cholecystectomy, suggesting additional opportunities to understand the barriers and facilitators of implementing prescribing guidelines into routine clinical practice.47 Likewise, guidelines that are already implemented may benefit from modification to align with current patient need and clinician practice patterns, such as the integration of multimodal pain management strategies. Given the high resource requirements of large-scale quality improvement efforts, continued focus on these high-yield areas will be an effective strategy in optimizing opioid stewardship.
Finally, we observed that for individuals aged 45 to 64 years, orthopedic procedures, such as joint replacement and arthroscopy, remained the most common procedures for which postoperative opioids are prescribed. These findings are consistent with prior studies demonstrating that orthopedic surgeons prescribe opioids more frequently than any other surgical specialty.14,19,48,49 For example, knee arthroplasty accounted for nearly 10% of all MMEs among individuals aged 45 to 64 years, and opioid prescriptions averaged approximately 51 pills containing 5-mg hydrocodone per procedure. Moreover, more than one-third of knee arthroplasty procedures involved an opioid prescription refill, suggesting that many patients’ pain levels remained high despite large initial prescriptions. These findings likely reflect the intensity and pain associated with musculoskeletal procedures, for which patient-reported pain is higher than other procedure types.50,51 Nonetheless, current recommendations advocate for multimodal pain management and caution against reliance on opioids as the sole strategy for postoperative analgesia in order to reduce the potential for opioid-related harms.52,53,54
Limitations
Our study findings should be interpreted in the context of several limitations. First, we recognize that the data included in this analysis are drawn primarily from 2021 and may not reflect the most current trends in prescribing in 2024. However, these data do represent the most recently available, procedure-level perspectives on perioperative opioid prescribing on a national scale, particularly following the COVID-19 pandemic. Second, our findings reflect only prescriptions that were dispensed based on administrative claims data and do not reflect patient-reported pain, actual opioid consumption, or the use of opioids from other sources, such as leftover pills from prior prescriptions. Similarly, our data sources do not allow us to capture the indication for prescribing or absolutely distinguish between opioids prescribed for surgical pain vs other reasons; however, we hope to mitigate this limitation by the inclusion of only those prescriptions in close proximity to the surgical discharge date. We are also unable to capture opioid alternatives that may have been prescribed or administered in addition to opioid analgesics for multimodal postoperative pain control. In addition, we used consensus across authors to map procedure codes to specific procedure types to aggregate codes by similarity. While the algorithm contains more than 1000 different procedures, it is possible that alternative mapping strategies could yield different findings. Furthermore, our findings only reflect prescribing patterns over a single year, drawn from administrative claims data. As such, the prescribing patterns we observed may not be generalizable to other groups, such as individuals without insurance coverage, and may not reflect future trends in postoperative prescribing.
Conclusions
In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures, including orthopedic procedures, cesarean delivery, and laparoscopic cholecystectomy, accounted for a large proportion of MMEs and opioid prescriptions dispensed after surgery. Going forward, targeted opioid stewardship initiatives focused on these procedures may provide the greatest value in optimizing postoperative opioid prescribing.
eAppendix 1. AHRQ Major Surgery Crosswalk
eAppendix 3. Surgical Procedures Accounting for the Greatest Proportion of MMEs, Prescriptions, Refills, and Opioid-Benzodiazepine Overlap by Age and Sex
eFigure. Study Cohort Flowchart
eAppendix 2. Complete List of Outcomes for All Procedure Types
eAppendix 4. List of Opioids and Their MME Conversion Factors
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eAppendix 1. AHRQ Major Surgery Crosswalk
eAppendix 3. Surgical Procedures Accounting for the Greatest Proportion of MMEs, Prescriptions, Refills, and Opioid-Benzodiazepine Overlap by Age and Sex
eFigure. Study Cohort Flowchart
eAppendix 2. Complete List of Outcomes for All Procedure Types
eAppendix 4. List of Opioids and Their MME Conversion Factors
Data Sharing Statement