Table 1.

Identified risk factors for opioid dependence following surgery

Pharmaceutical properties of drugs	Addictive properties of drugs. Modified release preparations. Compound analgesics.
Personal	Surgery and exposure to opioids. Past medical history of drug/alcohol dependence. Past medical history of psychological issues. Past medical history of chronic pain. Personality traits eg catastrophising personality.
Physician/prescribing	Poor knowledge surrounding safe opioid stewardship. Poor knowledge concerning acute and chronic pain prescribing. Use of repeat opioid prescriptions. The dispensing of long duration opioid prescriptions. Use of ‘weak’ opioids. Mistaken belief that dependence to prescribed opioids is rare. Failure to promote opioid deprescribing. Failure to educate patients on the importance of safe opioid stewardship.
Society	Opioid diversion. Lack of safe opioid disposal. Acceptability of ‘weak’ opioids. Deprivation.
Pharmaceutical industry	Aggressive marketing. Misbranding. False marketing claims about addiction to new longer-acting opioids. Sponsoring drug trials that are designed to demonstrate superiority of their products. Corporate greed. Involvement with researchers who are subsequently penalised for fabricating data.
Healthcare initiatives	Pain as the 5th vital sign campaign. Titrating opioids to numerical pain scores. Incentivisation eg payment by results and payment by patient reported outcome measures.
Under-provision of services	Lack of alternative resources/services to support people with chronic pain. Lack of recognition of chronic pain as a long-term condition.