​Patients continue to use opioids after surgery for complex reasons that go beyond surgical pain, state the authors of an original investigation published in JAMA Surgery. Citing wide variation and frequent excess in perioperative outpatient opioid prescribing, the authors conducted a population-based study of 36,177 insured individuals in the United States, examining incidence of "new persistent opioid use" (i.e., continued use at 90 days after surgery) and related risk factors for individuals undergoing minor or major surgical procedures. They found that risk of new persistent opioid use after surgery is common, similar between minor and major surgical procedures, and associated with a range of behavioral and pain disorders. Incidence of new persistent opioid use—as suggested by repeated opioid prescription fulfillment—was 5.9% after minor surgery and 6.5% after major surgery, compared to 0.4% in the nonoperative control group. Authors identified the following risk factors independently associated with new persistent opioid use: preoperative tobacco use, alcohol and substance use disorders, mood disorders, anxiety disorders, and preoperative pain disorders (i.e., back pain, neck pain, arthritis, and centralized pain). Additionally, individuals who received an opioid prescription in the 30 days prior to surgery had almost double the likelihood of persistent post-surgical opioid use, and those with more comorbidities were "particularly vulnerable to prolonged opioid abuse." The authors noted that despite a theoretical expectation that pain after major procedures would be greater than pain after minor procedures, new persistent opioid use did not differ between the two types of procedures. Therefore, the authors suggested, "prolonged opioid use following surgery may not simply be a consequence of poorly controlled pain." Given the known risks, new persistent opioid use is a poor outcome, and arguably an adverse event, concluded the authors.

HRC Recommends: Prescription opioid abuse poses a high risk for addiction, diversion, and subsequent heroin use. Furthermore, risk of long-term opioid use increases quickly after initial prescription (see HRC Alerts, March 29, 2017). Healthcare organizations may wish to consider adopting standardized tools and approaches for opioid prescribing and for identifying patients at increased risk. The knowledge that persistent opioid use is related to individual patient factors and not simply reflective of poorly controlled pain can help organizations work with prescribers to focus on patients who are at greatest risk.