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. 2024 Aug 1;281(3):347–352. doi: 10.1097/SLA.0000000000006461

Trends in Opioid Prescribing and New Persistent Opioid Use After Surgery in the United States

Alexandra O Luby *,†,✉, Dominic Alessio-Bilowus *,‡, Hsou Mei Hu *,‡, Chad M Brummett ‡,§, Jennifer F Waljee *,†,‡,∥, Mark C Bicket ‡,§,✉
PMCID: PMC11785817  PMID: 39087325

Abstract

Objective:

To define recent trends in opioid prescribing after surgery and new persistent opioid use in the United States.

Background:

New persistent opioid use after surgery among opioid-naive individuals has emerged as an important postoperative complication. In response, initiatives to promote more appropriate postoperative opioid prescribing have been adopted in recent years. However, current estimates of opioid prescribing and new persistent opioid use following surgery remain unknown.

Methods:

A retrospective cohort study of opioid-naive privately insured adult patients undergoing 17 common surgical procedures between 2013 and 2021 was conducted utilizing multi-payer claims data from the Health Care Cost Institute (HCCI). Initial opioid prescription size in oral morphine equivalents (OMEs) and new persistent opioid use were the outcomes of interest. Trends in opioid prescribing and rates of new persistent opioid use were evaluated across the study period. Mixed effects logistic regression was performed to evaluate independent predictors of new persistent opioid use while adjusting for patient-level factors and year.

Results:

Among 989,354 opioid-naive individuals, the adjusted initial opioid prescription size decreased from 282 mg OME to 164 mg OME, a reduction of 118 mg OME (95% CI: 116–120). The adjusted incidence of new persistent opioid use decreased from 2.7% in 2013 (95% CI: 2.6%–2.8%) to 1.1% in 2021 (95% CI: 1.0%–1.2%). For every 30 OME increase in initial opioid prescription size, new persistent opioid use increased by 3.1%. Other predictors of new persistent opioid use included preoperative nonopioid controlled substances fills [31–365 days: adjusted odds ratio (aOR)=1.78, 95% CI: 1.70–1.86; 0–30 days: aOR=2.71, 95% CI: 2.59–2.84] and undergoing orthopedic procedures [total knee arthroplasty (aOR=3.43, 95% CI: 3.15–3.72); shoulder arthroscopy (aOR=2.39, 95% CI: 2.24–2.56)].

Conclusions:

Both opioid prescription size after surgery and new persistent opioid use decreased over the last decade, suggesting that opioid stewardship practices had favorable effects on the risk of long-term opioid use.

Keywords: opioid, surgery, prescribing, new persistent opioid use, opioid stewardship, postoperative pain

Postoperative prescription opioids, while prescribed to address moderate-to-severe acute pain uncontrolled by over-the-counter medications, pose considerable, unintended risk for prolonged use in surgical patients. For example, greater opioid prescribing in the postoperative period is correlated with increased consumption and increased risk of new persistent opioid use among opioid-naive individuals, who continue to fill receive additional opioid prescriptions for months after the initial exposure during perioperative care.1–6 While definitions vary, recent studies have shown that 0.1% to 10% of surgical patients first exposed to opioid pain medications after both surgeries will develop new persistent opioid use.1,2,7 New persistent opioid use after surgery is associated with an increased long-term risk of complications, opioid use disorder, overdose, and death.3,8–15 Given the prevalence of excessive postoperative prescribing in the context of rising opioid-related morbidity and mortality in the United States, numerous strategies have been undertaken to optimize opioid stewardship and prevent opioid-related harms, including implementation of procedure-specific prescribing guidelines and even state-based and payer-based policies placing limits on prescribing for acute pain.8,16–24

In fact, the number of US states implementing new policies limiting opioid prescribing quadrupled between 2016 and 2019.25 With the advent of opioid stewardship initiatives to curb postoperative opioid prescribing, early concerns arose regarding adequate pain control postoperatively, which have since been addressed with multiple studies demonstrating that prescribing guidelines were successful at reducing opioid prescribing without negatively impacting patient satisfaction or pain control in smaller cohorts.18,19,26,27 However, the change in prescribing patterns and the rates of new persistent use on a national level over time remains largely unknown. A better understanding and assessment of how recent public health initiatives have impacted national prescribing patterns and rates of new persistent opioid use over time is important to determine the utility of ongoing efforts in this area and to reassess the appropriate allocation of resources for public health initiatives. Further, a more complete understanding of factors that influence rates of new persistent opioid use after surgery, including patient, prescriber, and procedure-related factors, would permit tailoring of future efforts.

To examine the impact of new guidelines and policies surrounding postoperative opioid prescribing, we assessed nationwide trends in postoperative opioid prescribing between 2013 and 2021 and new persistent opioid use. Specifically, we examined initial opioid prescription size, number of initial opioid prescriptions filled, and number of opioid prescriptions refilled as a measure of opioid prescribing. We hypothesized that new persistent opioid prescribing would decrease as initial opioid prescription size decreases over time.

METHODS

The University of Michigan institutional review board approved this retrospective cohort study with an exemption for informed consent due to deidentified data analysis. Reporting followed guidelines to Strengthen the Reporting of Observational Studies in Epidemiology (STROBE).

Data Source

Data was collected using the Health Care Cost Institute (HCCI) commercial claims research data sets, which is an employer-sponsored insurance claims database comprised of over 55 million covered lives per year in the United States. Data was collected between January 2013 and June 2021. This 8-year period represents the time period since the introduction of new evidence-based prescribing guidelines and policies to limit opioid prescribing for acute pain.19,25,28–30

Identification of Procedures and Cohort Selection

We selected 17 common elective and semielective surgical procedures and categorized these into minor and major groups based on prior studies.1,31 Minor surgical procedures included varicose vein removal, laparoscopic cholecystectomy, laparoscopic appendectomy, incisional hernia repair, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, carpal tunnel release, shoulder arthroscopy, and knee arthroscopy. Major procedures included bariatric surgery, colectomy, hysterectomy, reflux surgery, total hip arthroplasty, and total knee arthroplasty. These procedures were selected because these are common procedures for which opioid analgesics have been prescribed.1 To identify patients undergoing these procedures, we utilized Current Procedural Terminology, Fourth Edition (CPT-4) (Appendix A, Supplemental Digital Content 1, http://links.lww.com/SLA/F216). Only patients with continuous insurance coverage in the 12 months before admission for surgery and 6 months following discharge were included to capture preoperative comorbid conditions and identify prior opioid fills in the 1 year before surgery, as well as capture rates of new persistent use after surgery. We excluded patients who were less than 18 years old, those who were not discharged home, and those who underwent an additional procedure in the 6 months after the index procedure. Aligned with previous studies of opioid-naive surgical populations, patients who had filled 1 or more prescriptions for opioids 12 months to 31 days before their surgical procedure were excluded from the analysis (Supplement 1, Supplemental Digital Content 2, http://links.lww.com/SLA/F217).1,4,32 Inpatients with a length of stay of 30 days or greater and outpatients with a length of stay of 2 days or greater were also excluded.

Outcome Variables

The primary outcome of this study was the initial opioid prescription size filled between 30 days before admission and 3 days after discharge from the index surgery, measured in oral morphine equivalents (OMEs).4,32 This accounts for the type of medication, the dose prescribed, and the number of pills dispensed in the initial opioid prescription. Our secondary outcome of interest was new persistent opioid use, which was defined as filling at least one opioid prescription between postoperative days 4 to 90 and filling at least an additional opioid prescription between postoperative days 91 to 180 and was defined a priori before data collection.4,32 This definition of new persistent opioid use reflects a time period when routine postsurgical pain would be expected to be resolved for the procedures selected.

Patient Factors

We included sociodemographic and clinical covariates, including sex, age, insurance type, rural/urban, inpatient/outpatient, and length of stay. We classified patient comorbid medical diagnoses according to the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidities. The use of one or more controlled substances (ie, benzodiazepines, gabapentinoids, sedatives, hypnotics, or skeletal muscle relaxants) (Appendix B, Supplemental Digital Content 1, http://links.lww.com/SLA/F216) in the year before surgery was identified. We also recorded the presence of prior tobacco use history using ICD-9 and ICD-10 codes (Appendix C, Supplemental Digital Content 1, http://links.lww.com/SLA/F216). The Clinical Classification System from the Agency of Healthcare Research and Quality was used to identify mental health diagnoses. The subcategories of the mental health diagnoses by the Clinical Classification System were classified as adjustment disorders, anxiety disorders, mood disorders, suicidality (ie, suicide and intentional self-inflicted injury), personality disorders, schizophrenia, disruptive behavior disorders (ie, attention-deficit/hyperactivity disorder, conduct and disruptive behavior disorders, and impulse control disorders), other mental health conditions, and substance use disorders (ie, alcohol and other substance-related disorders). Preoperative pain conditions were identified using ICD-9 and ICD-10 codes (Appendix D, Supplemental Digital Content 1, http://links.lww.com/SLA/F216) and characterized as arthritis, back pain, neck pain, or other pain disorders. The inclusion of preoperative medical comorbidities, pain diagnoses, and mental health classifications was restricted to the 1-year preoperative study period.

Statistical Analysis

The overall goal of this study was to evaluate the trends in opioid prescribing and the incidence of new persistent opioid use over time. First, descriptive characteristics were tabulated for demographic variables and comorbidities for those filling opioid prescription and those who did not. In accordance with HCCI disclosure guidelines, reporting was only permissible with a minimum number of patients of 200 as identified based on procedure codes, and 800 as identified based on NDC codes. Therefore, results below this threshold were masked. Unadjusted rates of initial prescription fill, initial opioid prescription size, subsequent prescription refills, and new persistent opioid use were determined. Adjusted rates were then calculated for each metric. Multilevel, multivariable logistic, and linear regression models were used to account for the clustering effect of patients nested within a surgeon. The relationships between initial opioid prescription size and new persistent opioid use over time were examined while controlling for age, sex, history of tobacco use, mental health disorders, CCI, and pain disorders. Statistical tests were 2-tailed and significance was set at P<0.05. All analyses were conducted using Stata version 17.0 (StataCorp LLC) and SAS version 9.4 (SAS Institute Inc.).

RESULTS

In total, 989,354 patients met the inclusion criteria (Supplement 2a, Supplemental Digital Content 2, http://links.lww.com/SLA/F217). Most patients were female (55.8%) with mean age of 47.5 years (SD=12.8), and without comorbidities (CCI=0, 87.0%). Overall, 5.8% had a history of tobacco use, 17.1% had filled a prescription for a controlled substance other than an opioid prescription in the year before surgery, and 37.3% had a concomitant pain disorder diagnosis (arthritis, back pain, neck pain, or other pain). Patient characteristics differed between patients who developed new persistent opioid use and those who did not (Supplement 2b, Supplemental Digital Content 2, http://links.lww.com/SLA/F217). In univariate comparisons, more patients with new persistent opioid use filled a prescription for a controlled substance other than an opioid prescription in the year before surgery (33.2% vs 16.8%, P<0.001), had a history of tobacco use (8.6% vs 5.7%, P<0.001), had preoperative pain disorders, had anxiety or mood disorders, or reported preoperative alcohol and drug use.

Initial Opioid Prescription Size

Overall, the adjusted rate of an initial opioid prescription fills following surgery decreased by 3.5% over the study period [78.9% (95% CI: 78.7%–79.2%) to 75.4% (95% CI: 74.9%–75.3%)] (Fig. 1; Supplement 3, Supplemental Digital Content 2, http://links.lww.com/SLA/F217). Over the study period, the adjusted initial opioid prescription size decreased from 282 mg OME (95% CI: 280–284) to 164 mg OME (95% CI: 162–165). In addition, long-acting opioid prescriptions after surgery decreased from 1.7% of all opioid prescriptions in 2013 to 0.1% in 2021 (Supplement 4a–c, Supplemental Digital Content 2, http://links.lww.com/SLA/F217). The rate of opioid prescription refills within 30 days of the index procedure also decreased from 24.6% (95% CI: 24.3%–24.9%) to 13.6% (95% CI: 13.3%–14.0%) over the study period (Fig. 2; Supplement 5, Supplemental Digital Content 2, http://links.lww.com/SLA/F217).

FIGURE 1.

FIGURE 1

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Trends in postoperative opioid prescribing, 2013–2021. The adjusted rate of an initial opioid prescription fills following surgery decreased by 3.5% over the study period [78.9% (95% CI: 78.7%–79.2%) to 75.4% (95% CI: 74.9%–75.3%)], while the adjusted initial opioid prescription size decreased from 282 mg OME (95% CI: 280–284) to 164 mg OME (95% CI: 162–165), a reduction of 118 mg OMEs (95% CI: 116–120). The rate of opioid prescription refills within 30 days of the index procedure also decreased by 11.0% over the study period [24.6% (95% CI: 24.3%–24.9%) to 13.6% (95% CI: 13.3%–14.0%)].

FIGURE 2.

FIGURE 2

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Trends in rates of new persistent opioid use after surgery, 2013–2021. The adjusted incidence of new persistent opioid use decreased from 2.7% in 2013 (95% CI: 2.6%–2.8%) to 1.1% in 2021 (95% CI: 1.0%–1.2%), which represents a 1.6% absolute risk reduction over the study period.

Factors Associated With Initial Opioid Prescription Size

The initial opioid prescription size was significantly associated with the year of procedure and decreased by 118 mg OMEs (95% CI: 116–120) in 2021 compared with 2013 (Supplement 6, Supplemental Digital Content 2, http://links.lww.com/SLA/F217). Initial opioid prescription sizes varied substantially based on procedure type. Compared with the amount prescribed after laparoscopic cholecystectomy, patients filled larger opioid prescriptions after undergoing total knee arthroplasty, total hip arthroplasty, and shoulder arthroscopy of 351 mg additional OMEs (95% CI: 343−359), 303 mg additional OMEs (95% CI: 295−311), and 215 mg additional OMEs (95% CI: 211−220), respectively.

New Persistent Opioid Use

The adjusted incidence of new persistent opioid use decreased from 2.7% in 2013 (95% CI: 2.6%–2.8%) to 1.1% in 2021 (95% CI: 1.0%–1.2%), which represents a 1.6% absolute risk reduction over the study period (Fig. 2). Moreover, the odds of new persistent opioid use after surgery decreased over the study period with significantly lower odds of new persistent opioid use in 2021 compared with 2013 [adjusted odds ratio (aOR)=0.38, 95% CI: 0.35–0.42] (Supplement 7, Supplemental Digital Content 2, http://links.lww.com/SLA/F217).

Factors Associated With New Persistent Opioid Use

Across all study years, the probability of new persistent opioid use increased as initial opioid prescription size increased (Fig. 3). For every 10 tablets of 5 mg oxycodone, the odds of new persistent opioid use increased by 6% (aOR=1.06, 95% CI: 1.06–1.07) (Supplement 7, Supplemental Digital Content 2, http://links.lww.com/SLA/F217). Furthermore, patients who filled prescriptions for other controlled substances in the year (31–365 days) and month (0–30 days) before surgery had higher odds for developing new persistent opioid use after surgery [31–365 days: adjusted odds ratio (aOR)=1.78, 95% CI: 1.70–1.86; 0–30 days: aOR=2.71, 95% CI: 2.59–2.84]. Among all procedure types, patients undergoing total knee arthroplasty (aOR=3.43, 95% CI: 3.15–3.72), shoulder arthroscopy (aOR=2.39, 95% CI: 2.24–2.56), and colectomy (aOR=1.66, 95% CI: 1.43–1.93) had the highest odds of new persistent opioid use compared with those undergoing laparoscopic cholecystectomy in this study. In addition, those with a history of tobacco use (aOR=1.54, 95% CI: 1.43–1.65), preoperative alcohol or drug use (aOR=1.35, 95% CI: 1.22–1.48), or preoperative back pain (aOR=1.40, 95% CI: 1.30–1.50) also had higher odds of new persistent opioid use after surgery.

FIGURE 3.

FIGURE 3

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Adjusted probability of new persistent opioid use by initial opioid prescription size. The probability of new persistent opioid use increased as the initial opioid prescription size increased across all study years.

DISCUSSION

In this study evaluating national trends in postoperative opioid prescribing, opioid prescribing, and new persistent use after surgery declined between 2013 and 2021 in the United States. Notably, the initial opioid prescription size provided after surgery decreased by 41.8% over the study period, which is equivalent to ∼16 tablets of oxycodone 5 mg. Concurrently, the rates of new persistent opioid use after surgery declined by more than half to 1.1%. While the reasons for these changes are multifactorial, the steady decline among this national sample with private insurance provides encouraging evidence that the numerous public health efforts to increase awareness of the potential harms of excessive opioid prescribing and improve postoperative opioid stewardship have had a positive effect.

Our findings among a large cohort of privately insured adults undergoing the most common surgical procedures in the United States align with previous studies demonstrating the positive effects of prescribing guidelines on opioid fills among other samples.17,19,22,26,32,33 For example, one recent study examined rates of new persistent opioid use among Medicare beneficiaries after surgery at the state level after the implementation of state-specific opioid prescribing guidelines and found a significant decrease in the incidence of new persistent opioid use and reduction in the amount of opioids prescribed after surgery.32 While prior studies highlight the success of these programs at reducing new persistent use at the state level, the present study builds on this work and is notable for evaluating trends in perioperative prescribing at the national level and for generating more recent estimates that include the period up to 2021. Our results offer compelling evidence of decreased opioid prescribing, including decreased initial opioid prescription sizes postoperatively and decreased number of opioid prescription refills, accompanied by a decline in the rate of new persistent opioid use after surgery nationwide. Assuming that patient-related risk factors have remained largely unchanged over time, our results suggest that opioid stewardship initiatives to reduce excessive opioid prescribing have been successful in decreasing postoperative opioid prescribing as well as rates of new persistent opioid use after surgery, without an accompanying increase in opioid-naive patients seeking refills in the postoperative period.

In the context of prior work, the results of this study are encouraging, as excessive prescribing, a major driver of increased opioid consumption and persistent use, is a risk factor modifiable by surgeons, hospitals, and health systems, and decreasing trends in prescribing among public health initiatives suggest the positive impact of these programs on postoperative opioid stewardship.4,5 Moreover, it is encouraging that decreased postoperative opioid prescribing has not been shown to negatively impact patient satisfaction, postoperative pain control, or rate of opioid refills.18,19,26,27 Public health efforts to better inform prescribers through evidence-based prescribing guidelines, increased emphasis on nonopioid adjunctive therapies for postoperative pain, and even state and payer-based policies to limit opioid prescription duration for acute pain have likely all played a role in reducing excessive postoperative opioid prescribing and new persistent opioid use after surgery. However, previous studies examining state-based opioid stewardship efforts have mixed reports of effectiveness with some previous studies reporting positive impacts from state-level efforts, while others calling into question the effectiveness of state-level policy to produce meaningful change.28–30 Although the nationwide downward trends in postoperative opioid prescribing and rates of new persistent opioid use appear encouraging, it remains imperative that we continue to assess the impact of ongoing efforts at the national level to effectively gauge progress and to appropriately allocate public health resources based on exigency. While current initiatives have largely focused on reducing excessive prescribing, future strategies should include more targeted approaches to reduce prescribing of high-volume prescribers, including surgeons performing total hip and knee arthroplasty and shoulder arthroscopy, and to improve our screening and intervention strategies for patients at risk and those who develop persistent use.34 The findings of this study support the value of ongoing public health initiatives to improve postsurgical opioid stewardship and assuage opioid-related adverse events, with important implications for all stakeholders, including patients, prescribers, payers, and policy makers alike.

Limitations

These findings should be considered in the context of limitations. First, this study relies on administrative claims data from a privately insured patient population, which may not be generalizable to other patient populations, including the uninsured or Medicaid and Medicare beneficiaries. However, the sample of persons with claims captured in Health Care Cost Institute data is large and represents a diverse sample of procedures. Second, administrative claims data lacks clinical granularity, such as information regarding opioid consumption, reasons for continued use, and relevant patient-reported outcomes such as pain or satisfaction. Third, while we cannot demonstrate causality, our findings suggest that reductions in initial opioid prescribing and new persistent opioid use after surgery occurred at the same time, which supports the view that public health efforts to improve opioid stewardship have likely contributed to successful ways to reducing postoperative opioid prescribing and the risk of developing new persistent opioid use.

CONCLUSIONS

Encouragingly, both opioid prescription size after surgery and new persistent opioid use have decreased nationwide since 2013. Specifically, initial opioid prescription sizes decreased by 41.8% over the study period, and new persistent opioid use decreased by more than half from 2.7% to 1.1%. These trends over time suggest that increased awareness of opioid-related harms can promote opioid stewardship, which has favorable effects on the risk of long-term opioid use. Evidence-based guidelines and policies that limit inappropriate prescribing for acute pain are important components of current strategies to reduce opioid-related harms after surgery. Ongoing efforts to support opioid stewardship initiatives remain imperative to protect patients from opioid-related risks after surgery.

Supplementary Material

sla-281-347-s001.docx (21KB, docx)
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sla-281-347-s002.docx (268.2KB, docx)
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Footnotes

This work was supported by the National Institute on Drug Abuse (NIH/NIDA R01 DA057284) and the Michigan Department of Health and Human Services.

C.M.B. is a consultant for Vertex Pharmaceuticals and Merck Pharmaceuticals, and he previously consulted for Heron Therapeutics. He also provides expert medical testimony. M.B.C. reports funding from the Blue Cross Blue Shield of Michigan and past funding from the Arnold Foundation. The remaining authors report no conflicts of interest.

Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.annalsofsurgery.com.

Contributor Information

Alexandra O. Luby, Email: alexalub@med.umich.edu.

Dominic Alessio-Bilowus, Email: alessina@med.umich.edu.

Hsou Mei Hu, Email: hsoumeih@med.umich.edu.

Chad M. Brummett, Email: cbrummet@med.umich.edu.

Jennifer F. Waljee, Email: filip@med.umich.edu.

Mark C. Bicket, Email: mbicket@med.umich.edu.

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