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. Author manuscript; available in PMC: 2026 Mar 1.
Published in final edited form as: Anesthesiology. 2025 Sep 25;144(2):431–440. doi: 10.1097/ALN.0000000000005771

Trends in Use of Medications for Opioid Use Disorder among Commercially Insured U.S. Surgical Patients, 2016–2022

Mark C Bicket 1,2,3, Xiaoyuan Qi 3, Kyle Buchwalder 4, Kao-Ping Chua 3,5, Pooja Lagisetty 6,7, Vidhya Gunaseelan 1,2, Jennifer F Waljee 2,7, Chad M Brummett 1,2, Yi Li 8, Thuy Nguyen 3
PMCID: PMC12949413  NIHMSID: NIHMS2147563  PMID: 40997040

Abstract

Background:

The optimal management of perioperative pain in patients using medications for opioid use disorder (MOUD) is unclear. To motivate and inform efforts to develop evidence-based guidelines for perioperative pain management in these patients, it is important to evaluate whether the prevalence of MOUD use in surgical patients is increasing and to identify which procedures have the highest rate of MOUD use.

Methods:

This cohort study analyzed adults 18–64 years undergoing one of 1083 major surgical procedures from 2016 to 2022 from the Merative MarketScan Commercial Database, which includes commercial claims from 22–28 million privately insured patients annually. Annual changes in MOUD use from 1–180 days before surgery were evaluated using logistic regression models adjusting for patient demographics and comorbidities. For each procedure category, the prevalence of MOUD use among all instances of the procedure during 2016–2022 was calculated.

Results:

Analyses included 8,137,973 surgical admissions for 5,013,213 adults (59.9% female). The adjusted prevalence of MOUD use increased from 55.2 per 100,000 in 2016 to 99.8 per 100,000 in 2022 (adjusted annual change, 16.9 per 100,000 procedures, 95% CI 14.0 to 19.8). Among 15,701 surgical admissions for patients using MOUD during 2016–2022, the most common type of MOUD was buprenorphine (13,193; 84.0%). Procedures with the highest rate of MOUD use were debridement (719.0 per 100,000 procedures), shoulder arthroplasty (579.4 per 100,000 procedures), lower extremity amputation (529.6 per 100,000 procedures), and hip or pelvis open fracture repair (497.6 per 100,000 procedures).

Conclusions:

In this cohort study of surgical procedures among privately insured US adults the prevalence of MOUD use increased between 2016 and 2022, highlighting the importance of developing evidence-based guidelines for perioperative management of these patients. The high rates of MOUD use in common orthopedic procedures suggest these guidelines may be particularly relevant to the practice of orthopedic surgeons.

Introduction

Medications for opioid use disorder (MOUD), which include buprenorphine, methadone, and naltrexone, prevent overdose, promote recovery, and reduce death among persons with opioid use disorder (OUD).1 As mortality from opioid overdose has increased dramatically in recent years, with more than 79,358 deaths in 2023,2 a key principle of public health campaigns by federal, state, and other entities to address the crisis and save lives has been the expansion in access to and use of MOUD. As MOUD, both buprenorphine and methadone lead to opioid tolerance, while naltrexone directly blocks mu opioid receptors.3–5 Relevant to surgical care, MOUD requires nuanced perioperative planning particularly related to pain management, given that all MOUD act on and most compete for the same receptors as commonly administered and prescribed opioid analgesics.6,7

In the United States, more than 2.3 million people received MOUD in 2022.8 An analysis examining prescribing claims between 2016 and 2022 across 92% of retail pharmacies suggested that the number of patients initiating buprenorphine increased from 12.5 to 15.9 per 100,000 over two years and then plateaued after 2018, while only one in five patients were retained on treatment beyond 180 days of therapy.9 However, significant knowledge gaps exist regarding MOUD use among surgical patients, especially given public health campaigns and policy changes to increase MOUD prescribing. It is unknown how commonly surgical patients use MOUD or how the epidemiology of perioperative MOUD use has changed in recent years. Closing this knowledge gap could motivate efforts to develop evidence-based guidelines for perioperative pain management for patients using MOUD, which currently do not exist. Furthermore, identification of the procedures with the highest rate of MOUD use could identify the clinical settings in which dissemination and implementation of such guidelines are most important.

We conducted a national study to assess trends in MOUD use among privately insured adults undergoing surgery between 2016 and 2022. We also determined the types of surgical procedures with the highest rates of MOUD use. Uncovering the areas of surgical practice with the highest rates of MOUD use before surgery could lead to better tailored strategies and more focused resources to advance the care of these patients before, during, and after surgery.

Materials and Methods

Data Source

The data source was the Merative MarketScan Commercial Database, which includes medical and pharmacy claims for 22–28 million Americans annually aged 0–65 years with employer-based private insurance coverage. Because this data is deidentified, the University of Michigan Medical School Institutional Review Board approved this cohort study as exempt from human subject review. Reporting follows Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cohort studies and an analytical protocol was registered prior to data analysis.10

Sample

Analyses were conducted at the level of surgical procedures. To identify these procedures, we used our previously developed algorithm, which maps Current Procedural Terminology (CPT) codes for major surgery identified by the Agency for Healthcare Research and Quality’s (AHRQ) Surgery Flags for Services and Procedures algorithm to one of 1083 procedure categories.11,12 Analyses included surgical procedures occurring between April 1, 2016 to December 31, 2022, for patients who had 180 days of continuous enrollment before surgery or surgery admission through to discharge (eFigure 1). Claims from April 2016 were used in the analysis to ensure that the 180-day look-back period occurred after the ICD-10-CM transition. We excluded procedures for persons aged <18 years or aged >64 years and those performed for patients in Puerto Rico. Exclusions also apply to procedures for patients lacking continuous enrollment for 180 days prior to surgery or from admission through discharge. Finally, for multiple procedures that occurred on the same date for a patient, we assigned a single procedure to each admission if they appeared more frequent based on the distribution of the procedures (after excluding these multiple procedures).

Outcomes

The primary outcome was the use of MOUD, defined as a medical or pharmacy claim between 1 and 180 days before surgery for buprenorphine, methadone, or extended-release naltrexone. Diagnosis codes for OUD were not required, given concerns about the accuracy of such codes and lack of a valid diagnostic code measure in claims data.13,14 Buprenorphine included branded and generic formulations but excluded transdermal and buccal film routes given their sole indication for chronic pain treatment. Both national drug codes and Healthcare Common Procedure Coding System (HCPCS) codes were used to identify MOUD (see eMethods for full HCPCS code list). Secondary outcomes were the use of individual types of MOUD (buprenorphine, methadone, and extended-release naltrexone) in the 1 to 180 days prior to surgery.

Statistical analysis

Data analysis was conducted from November 2024 to February 2025. We described the characteristics of patients as of the time of the procedure, including age in years (18–34, 35–44, 45–54, 55–64), sex (male, female), rurality (rural indicated by non-Metropolitan Statistical Area [MSA], urban indicated by MSA, and unknown),15 region (Northeast, Midwest, South, West, unknown), and insurance plan cost share (low [basic/major medical, EPO, HMO, Comprehensive, POS w cap], medium [PPO, POS], high [HDHP, CDHP], unknown).16 Race and ethnicity data were not available in the database. Based on diagnosis codes in the 1 to 180 days prior to admission for surgery, we also calculated the prevalence of mental health and substance use disorders, defined using AHRQ Clinical Classifications Software Refined categories,17 as well as a modified Elixhauser mortality score that excluded domains listed as mental health or substance use disorders. For each year, we calculated the unadjusted prevalence of any MOUD use and use of specific MOUD types, expressed as the number of procedures per 100,000. Additionally, we calculated the unadjusted prevalence of MOUD use by patient demographic characteristics. We used multivariable logistic regression models that modeled MOUD use as a function of continuous year, adjusting for covariates (age, sex, region, rurality, employment status, plan cost share, mental health conditions, substance use disorders, modified Elixhauser score). As patients could contribute to more than one episode to the dataset (1,557,411 patients with multiple episodes [4,682,171]), observations within a patient may not be independent. Therefore, we used clustered standard errors at the patient level in all logistic regressions to reduce bias in estimated standard errors. The logistic model achieved a C statistic of 0.87, reflecting robust sensitivity and specificity and ability of our logistic regression model to correctly assign a higher risk of an outcome to the patients who are truly at higher risk.18 We converted odds ratios to average marginal effects to express the year-over-year change as absolute changes in the number of procedures with the outcome per 100,000 procedures. When calculating the prevalence of specific types of MOUD, we included individuals with multiple MOUD exposures (e.g., buprenorphine and methadone) under each relevant type.

To identify procedures with the highest prevalence of MOUD use, we pooled all instances of the procedures during 2016–2022, then limited to those in which the sample size was ≥10,000, a threshold of ~0.1% of admissions defined a priori as being large enough for reliable estimates. We ranked the remaining procedures by prevalence of MOUD use in the 1 to 180 days before surgery to identify the top ten procedures, for which we examined annual trends in MOUD use within 180 days before surgery. In additional analyses, we examined MOUD use among the subgroup of surgical patients with a diagnosis of OUD, compared year-over-year change in prevalence in models with and without mental health and substance use disorder diagnoses, and examined residuals (standardized Pearson, deviance, leverage) and applied Firth’s logistic regression for sparse data given cases were <1% of sample. Analyses were conducted using Stata/MP 18 and used two-sided hypothesis test with alpha=0.05.

Results

Sample characteristics

Analyses included 8,137,973 surgical admissions. As shown in Table 1, most procedures were for patients who were female (4,876,884; 59.9%), resided in an urban area (6,034,681; 74.2%) and were actively employed (5,884,169; 72.3%). Most procedures were for patients with medium insurance plan cost share (4,873,502; 59.9%), while 58,506 (0.7%) had an OUD diagnosis. Characteristics were similar for each year of the study period, with the except of anxiety and depression (eTable 1). The percentage of surgical admissions of patients with anxiety in the prior 6 months increased from 10.5% in 2016 to 15.9% in 2022 while those with depression increased from 8.9% to 11%. Among the 15,701 surgical procedures for patients with MOUD use, most were for patients who were male (8,355; 53.2%), resided in the South (7,584; 48.3%), and had an OUD diagnosis (9,251; 58.9%). For MOUD use, most procedures were for patients who used buprenorphine (13,193; 84.0%), followed by methadone (1,046; 6.7%), and naltrexone (1,546; 9.8%) (eTable 2).

Table 1.

Characteristics of surgical procedures by use of medications for Opioid Use Disorder (MOUD), 2016–2022

Characteristic Surgical Procedures, no. (%)
Overall No MOUD Use Before Surgery MOUD Use Before Surgery SMD
N 8,137,973 8,122,272 15,701
Age group, y 0.20
 18–34 1387196 (17.0%) 1384706 (17.0%) 2490 (15.9%)
 35–44 1374186 (16.9%) 1370571 (16.9%) 3615 (23.0%)
 45–54 2002538 (24.6%) 1998173 (24.6%) 4365 (27.8%)
 55–64 3374053 (41.5%) 3368822 (41.5%) 5231 (33.3%)
Sex 0.27
 Male 3261089 (40.1%) 3252734 (40.0%) 8355 (53.2%)
 Female 4876884 (59.9%) 4869538 (60.0%) 7346 (46.8%)
 Rurality 0.09
 Urban 6034681 (74.2%) 6023638 (74.2%) 11043 (70.3%)
 Rural 1064423 (13.1%) 1062088 (13.1%) 2335 (14.9%)
 Other1 1038869 (12.8%) 1036546 (12.8%) 2323 (14.8%)
Region 0.03
 Northeast 1256227 (15.4%) 1253695 (15.4%) 2532 (16.1%)
 Midwest 1713911 (21.1%) 1710698 (21.1%) 3213 (20.5%)
 South 3949379 (48.5%) 3941795 (48.5%) 7584 (48.3%)
 West 1200790 (14.8%) 1198441 (14.8%) 2349 (15.0%)
 Other1 17666 (0.2%) 17643 (0.2%) 23 (0.1%)
Plan cost share 0.09
 Low 1201174 (14.8%) 1198584 (14.8%) 2590 (16.5%)
 Medium 4873502 (59.9%) 4863805 (59.9%) 9697 (61.8%)
 High 1906533 (23.4%) 1903361 (23.4%) 3172 (20.2%)
 Other1 156764 (1.9%) 156522 (1.9%) 242 (1.5%)
Employment status 0.11
 Active 5884169 (72.3%) 5873052 (72.3%) 11117 (70.8%)
 Retired 652160 (8.0%) 651032 (8.0%) 1128 (7.2%)
 Disabled 59735 (0.7%) 59464 (0.7%) 271 (1.7%)
 COBRA2 87063 (1.1%) 86799 (1.1%) 264 (1.7%)
 Other3 1454846 (17.9%) 1451925 (17.9%) 2921 (18.6%)
Substance use disorders
 Tobacco use disorder 408174 (5.0%) 404298 (5.0%) 3876 (24.7%) 0.58
 Alcohol use disorder 86273 (1.1%) 84090 (1.0%) 2183 (13.9%) 0.50
 Cannabis use disorder 26611 (0.3%) 25871 (0.3%) 740 (4.7%) 0.28
 Opioid use disorder 58506 (0.7%) 49255 (0.6%) 9251 (58.9%) 1.66
 Non-opioid drug use disorder 38004 (0.5%) 35745 (0.4%) 2259 (14.4%) 1.66
Psychiatric conditions
 Anxiety 1057496 (13.0%) 1051733 (12.9%) 5763 (36.7%) 0.57
 Depression 809486 (9.9%) 804337 (9.9%) 5149 (32.8%) 0.58
Elixhauser index, mean (SD)4 0.9 (3.1) 0.9 (3.1) 1.0 (2.9) −0.03
 Year 0.16
 2016 1111380 (13.7%) 1109664 (13.7%) 1716 (10.9%)
 2017 1314634 (16.2%) 1312471 (16.2%) 2163 (13.8%)
 2018 1280313 (15.7%) 1277918 (15.7%) 2395 (15.3%)
 2019 1245996 (15.3%) 1243805 (15.3%) 2191 (14.0%)
 2020 1072089 (13.2%) 1069877 (13.2%) 2212 (14.1%)
 2021 1078475 (13.3%) 1075944 (13.2%) 2531 (16.1%)
 2022 1035086 (12.7%) 1032593 (12.7%) 2493 (15.9%)
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Notes: medications for Opioid Use Disorder (MOUD), standardized mean difference (SMD).

1.

Other groups include unknown and missing.

2.

Consolidated Omnibus Budget Reconciliation Act (COBRA) plans includes surviving spouse and dependent plans.

3.

Other groups include other insurance plans and missing.

4.

The Elixhauser mortality index was modified to exclude any diagnosis listed as chronic conditions (i.e., substance use and psychiatric conditions).

Prevalence of MOUD Use Among Surgical Patients

In 2016, the prevalence of MOUD use was 154.4 per 100,000 procedures; in 2022, the prevalence increased to 240.8 per 100,000 procedures (Figure 1). In adjusted models, this change represented an annual change per year in prevalence of 16.9 (95% CI 14.0 to 19.8) per 100,000 procedures (Table 2). Most of this growth was attributable to increases in buprenorphine use, while increases in methadone and naltrexone contributed to a lesser extent.

Figure 1.

Figure 1.

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Changes in the prevalence of medication for opioid use disorder use among privately insured patients undergoing surgical procedures, 2016 to 2022

A. Any MOUD, unadjusted

B. Type of MOUD, unadjusted

C. Any MOUD, adjusted

D. Type of MOUD, adjusted

Medications for Opioid Use Disorder (MOUD) were measured based on medical or pharmacy claims between 1 and 180 days before the date of the surgical procedure. MOUD included buprenorphine (medical or pharmacy claims), extended-release naltrexone (medical or pharmacy claims), methadone (medical claims only), and unspecified MOUD (medical claims designating MOUD provision without specifying a drug product). Data for 2016 includes procedures from April 1, 2016 to December 31, 2016; other years include procedures from January 1 to December 31. Prevalence was calculated without adjustment for overall (A) and by type (B) of MOUD, as well as in models adjusting for age, sex, employment status, rurality, region, plan cost share, seven mental health and substance use disorder conditions, and modified Elixhauser score for overall (C) and by type (D) of MOUD.

Table 2.

Change in prevalence of medications for opioid use disorder by surgical patients, 2016–2022

Medications to treat opioid use disorder (MOUD) Adjusted prevalence of MOUD use per 100,000 procedures (95% CI) Adjusted year over year change
2016 2022
Any MOUD 55.2 (51.0 to 59.4) 99.8 (92.8 to 106.9) 16.9 (14.0 to 19.8)
Buprenorphine 51.1 (47.2 to 55.0) 78.5 (72.6 to 84.4) 10.7 (8.51 to 12.9)
Methadone 0.10 (0.04 to 0.3) 1.1 (0.7 to 1.6) 4.6 (2.25 to 6.95)
Extended-release naltrexone 2.5 (1.9 to 3.1) 5.2 (4.2 to 6.3) 1.7 (1.04 to 2.41)
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Note: Absolute difference presented as average marginal effects per 100,000 surgical procedures. MOUD were measured based on medication fills or service claims between 1 and 180 days before the date of the surgical procedure. MOUD included buprenorphine (medical or pharmacy claims), extended-release injectable naltrexone (medical or pharmacy claims), and methadone (medical claims only). Data for 2016 includes procedures from April 1, 2016, to December 31, 2016; other years include procedures from January 1 to December 31. Prevalence was calculated in models adjusting for age, sex, employment status, rurality, region, plan cost share, chronic conditions, and a modified Elixhauser score.

Changes in the prevalence of MOUD use varied by patient groups (Figure 2; eTable 3), with an increase between 2016 and 2022 across all age groups, except for procedures for surgical patients aged 18–34 years old, which decreased slightly (unadjusted change −55.1 per 100,000 procedures). Procedures for male surgical patients had larger increases in MOUD use than those for female patients in unadjusted models (unadjusted change 114.0 vs. 66.0 per 100,000 procedures, respectively), and a similar relationship was found in adjusted models (adjusted change 92.9 [95% CI 80.2 to 105.5] for males). Procedures for rural surgical patients had larger increases in MOUD than urban patients (unadjusted change 142.3 vs. 59.6 per 100,000 procedures, respectively). MOUD increased across all regions, with larger increases for procedures in the Midwest and Northeast (121.7 and 120.5 per 100,000 procedures, respectively) compared to the West (40.1 per 100,000 procedures) and the South (78.0 per 100,000 procedures).

Figure 2.

Figure 2.

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Changes in the prevalence of medication for opioid use disorder use among surgical patients by demographic characteristics, 2016 to 2022

A. Age group

B. Sex

C. Rurality

D. Region of residence

Prevalence of medication for opioid use disorder use by age (A), sex (B), rural/urban status (C), and region (D). Rurality was classified based on whether patients resided in a metropolitan statistical area. MOUD were measured based on medication fills or service claims between 1 and 180 days before the date of the surgical procedure. MOUD included buprenorphine (medical or pharmacy claims), extended-release injectable naltrexone (medical or pharmacy claims), methadone (medical claims only), and unspecified MOUD (medical claims designating MOUD provision without specifying a drug product). Data for 2016 includes procedures from April 1, 2016 to December 31, 2016; other years include procedures from January 1 to December 31. Prevalence is unadjusted.

Analysis by Procedure Type & Additional Analyses

A total of 101 procedure types had 10,000 or more procedures in the sample during 2016–2022, which accounted for 7,374,369 procedures, or 90.6 (%) of all 8,137,973 procedures in the sample. Among the top 101 procedure types, the prevalence of MOUD use was highest for debridement (unadjusted prevalence 719.0 per 100,000 procedures), followed by 3 orthopedic procedures: shoulder arthroplasty, lower extremity amputation, and hip or pelvis fracture open repair. The procedure types with the seventh, eighth and tenth highest rates of MOUD use were also orthopedic procedures (clavicle open fracture repair, upper extremity tendon repair, and lower extremity arthrodesis). Figure 3 (eTable 4) shows the prevalence of MOUD use among the procedure types with the 10 highest rates of MOUD use, with close alignment in unadjusted and adjusted MOUD prevalence estimates. eFigure 2 shows trends in prevalence of MOUD use for these ten procedures, with consistency across procedures for buprenorphine at the most used MOUD. MOUD use among surgical patients limited to the subgroup with a diagnosis of OUD revealed similar increases during 2016–2022, with the few differences in MOUD use among procedures including increases for patients in the 18–34 year-old group relative to the 45–54 year-old group, declines for disabled relative to actively employed patients, and no changes for depression, anxiety, and alcohol use disorder (eTable 5). A sensitivity analysis comparing models with and without adjustment of mental health and substance use disorder conditions identified no differences in changes in MOUD from 2016 to 2022 (year-over-year change 16.9 [95% CI 14.0 to 19.8] vs. 14.5 [95% CI 11.3 to 17.7]) (eTable 6), which was also similar when examining Firth’s models (year-over-year change 14.9 [95% CI 14.3 to 15.4]) (eTable 7, eFigure 3).

Figure 3.

Figure 3.

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Top 10 procedures by surgical patient use of medications for opioid use disorder (MOUD), 2016–2022

Note: Bars indicate prevalence expressed in units per 100,000 procedures with 95% confidence intervals. Surgical procedures were required to have ≥10,000 cumulative procedures to be included in this sample. Medications for opioid use disorder (MOUD) were measured based on medication fills or service claims between 1 and 180 days before the date of the surgical procedure. MOUD included buprenorphine (medical or pharmacy claims), and extended-release injectable naltrexone (medical or pharmacy claims), methadone (medical claims only). Data includes procedures from April 1, 2016 to December 31, 2022. Prevalence of MOUD use was calculated in unadjusted models and models adjusting for age, sex, employment status, rurality, region, plan cost share, seven mental health and substance use disorder conditions, and modified Elixhauser score.

Discussion

In this national study of surgical procedures for patients with private insurance coverage, the prevalence of MOUD use increased from 154.4 to 240.8 per 100,000 procedures between 2016 and 2022. The increase in MOUD use among surgical procedures resulted primarily from greater use of buprenorphine, which accounted for 84.0% of all procedures with MOUD use during the study period. Orthopedic procedures accounted for the majority of the top 10 procedures in terms of the prevalence of MOUD use. In the case of shoulder arthroplasty, more than 1 in 200 procedures were performed on patients with MOUD.

The observation that MOUD use among surgical admissions increased has not been shown in prior studies of surgical care, though it largely aligns with existing work examining trends in MOUD among non-surgical populations over the past ten years. For example, in one study, the use of any type of MOUD rose from 47.8% to 57.1% between 2014 and 2018 among Medicaid enrollees with OUD who resided in 11 states.19 In another study, the annual U.S. rate of buprenorphine prescription fills for formulations approved for OUD increased from 2.0 to 4.4 per 1,000 persons between 2009 and 2019.20 Further, the prevalence of MOUD use increased in all age subgroups except in patients aged 18 to 34 years in both of these two studies, which is consistent with our finding that MOUD significantly decreased among surgical admissions for young adults. Overall, the rise in surgical MOUD prevalence also appears consistent with national outpatient buprenorphine prescribing trends.9 Lower rates of MOUD use among surgical persons aged 18 to 34 years old relative to other age groups may have been due to decreased healthcare utilization and increased cost barriers relative to other age groups.21 Higher rates of MOUD prevalence in the Northeast may have resulted from proactive policy initiatives and higher density of waivered prescribers for MOUD relative to other regions.22 Results from the population-based estimates from the 2022 National Survey of Drug Use and Health survey mirrored our finding for lower use of MOUD among female surgical patients but not for higher rates among rural surgical patients.23

The growth in MOUD use among patients undergoing surgical procedures highlights the importance of developing evidence-based guidelines for perioperative pain management in the context of MOUD use. Both surgeons and primary clinicians may not feel comfortable managing MOUD in the period during and after surgery, where complexities in pain management may exacerbate existing challenges in clinical knowledge, organizational support, and professional identity.24 Current practice guidelines on this topic are based on largely on expert opinion and often conflict, with some suggesting buprenorphine discontinuation before surgery and others recommending continuation.6,25 A robust effort is needed to generate rigorous evidence on the effects of MOUD discontinuation versus continuation on key outcomes, such as pain control and opioid-related adverse events, such as overdose. All clinicians with a Drug Enforcement Agency license to prescribe controlled substances such as opioid prescriptions have the ability to prescribe buprenorphine as MOUD because of the removal in January 2023 of the requirement for a waiver from the Drug Enforcement Administration. While this policy action greatly expanded the pool of potential prescribers, notable increases in patient access have failed to materialize in the year that followed.8

Our findings suggest that orthopedic procedures, such as shoulder arthroplasty, lower extremity amputation, and hip or pelvis fracture repair, have some of the highest rates of MOUD use alongside procedures consistent with skin infections and sequalae from intravenous drug use. Potential reasons for high rates among orthopedic procedures include that patients with comorbid pain and OUD may preferentially undergo orthopedic procedures, or that buprenorphine was initiated independently of surgical timing given the wide range in treatment examined before surgery. Regardless of the reason, this finding suggests that evidence-based guidelines for perioperative pain management in patients using MOUD are particularly important to develop and disseminate in the context of orthopedic surgery. This insight is consistent with the conclusions of several prior studies on opioid prescribing, which showed that orthopedic surgery accounted for the greatest share of prescribing after surgery and therefore should be prioritized in surgical opioid stewardship initiatives.26–28 Until more rigorous evidence and guidelines on perioperative pain management for patients with MOUD use are developed and widely adopted, the surgical community and in particular those who care for orthopedic patients should be increasingly aware of the rise in MOUD treatment during the preoperative period. As this community is likely to encounter more patients on MOUD, they are encouraged to proactively ask about this treatment during assessments and to coordinate with their team to create a safe management plan to mitigate potential risks of adverse harms.29–32 Current clinical recommendations for patients on MOUD based on multisociety guidelines from ASRA and other national groups involve not routinely discontinuing buprenorphine in the surgical period, emphasizing multimodal analgesia, and detailing a tapering plan when prescribing additional full agonist opioids for postoperative pain.6,7 Recent analysis of Veterans Affairs surgical procedures suggests that patients on buprenorphine for MOUD do not report higher pain scores or require more opioids in the first few days to weeks after surgery.33 An emerging consensus to minimize the risk of potential relapse for elective surgery is continuation of perioperative MOUD for buprenorphine and methadone and case-by-case evaluation of naltrexone.

Limitations

These findings should be considered in the context of important limitations. First, methadone for MOUD may only be identified via procedural codes in medical claims and may be undermeasured due to differences in its delivery and billing.19 Given 40% of surgical procedures with MOUD did not have an associated OUD diagnosis, concern may also exist that some prescriptions may have not been for OUD, such as buprenorphine for pain or naltrexone for alcohol use disorder. Underdiagnosis of OUD is known due to stigma and other causes.34 Further, the analysis excluded buprenorphine products approved only for the treatment of chronic pain and included only the injectable form of naltrexone, the only route currently approved for the treatment of OUD. Second, these findings rely on analysis of private, employer-based insurance claims, which limit their generalizability to and do not represent other important populations such as publicly insured beneficiaries of Medicaid which may have higher rates of OUD and different access to MOUD, though more than 54% of persons in the United States had employment-based insurance in 2022.35,36 Third, claims data lack clinical details that offer additional context for surgical care, such as whether procedures were elective versus emergent. Fourth, it was beyond the scope of this study to measure MOUD discontinuation before surgery. Our analyses are best conceptualized as examining trends in the proportion of surgical procedures for patients who had used MOUD in the 180 days preceding surgery, but some of those patients may have discontinued MOUD before surgery. Fifth, diagnostic codes offer one potential measure of patient characteristics, though misclassification may be possible, especially for mental health and substance use related diagnoses.

Conclusion

In this national cohort study, the prevalence of MOUD use among surgical procedures for privately insured patients increased from 2016 to 2022. This prevalence was especially high in orthopedic procedures. Collectively, findings highlight the growing need to develop and disseminate evidence-based guidelines for perioperative pain management in patients with OUD, particularly for patients undergoing orthopedic procedures. The growing use of MOUD by patients before surgery emphasizes the need for clinicians in both surgery and primary care to support tailored strategies to address the complex perioperative management and pain needs of these patients.

Supplementary Material

Supplemental Material

Acknowledgements:

The authors would like to thank Raman Singh, MS, for assistance with data management of this study.

Funding Statement:

Research reported in this publication was supported by the National Institute of Drug Abuse of the National Institutes of Health under award number R01DA057943. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of Interest:

Dr. Bicket reports grants from NIH, PCORI, CDC, FDA, Michigan Department of Health and Human Services/SAMHSA, and Blue Cross Blue Shield of Michigan outside of this work. Dr. Brummett reports consulting for Vertex Pharmaceuticals and Merck Pharmaceuticals and providing expert medicolegal testimony. The other authors report no conflicts.

Abbreviations:

MOUD

Medications for opioid use disorder

OUD

opioid use disorder

Footnotes

Prior Presentations: Preliminary findings were presented at the Association of University Anesthesiologists meeting in Boston, MA on March 8, 2025.

References

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