Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Postsurgical Opioid Prescribing & Potential Misuse

BMJ; ePub 2018 Jan 17; Brat, Agniel, et al

Among opioid naïve patients undergoing surgery, each refill and week of opioid prescription is associated with a large increase in opioid misuse, a recent study found. The retrospective cohort study included 1,015,116 opioid native patients undergoing surgery between 2008 and 2016. Researchers found:

  • 568,612 (56.0%) patients received postoperative opioids, with abuse identified in 5,906 patients (0.6%, 183 per 100,000 person-years).
  • Total duration of opioid use was the strongest predictor of misuse, with each refill and additional week of opioid use associated with an adjusted increase in rate of misuse of 44.0% (40.8% to 47.2%), and 19.9% increase in hazard (18.5% to 21.4%), respectively.
  • Duration of a prescribing rather than opioid dosage was strongly associated with ultimate misuse in the early postsurgical period.


Brat GA, Agniel D, Bean A, et al. Postsurgical prescriptions for opioid naïve patients and association with overdose and misuse: Retrospective cohort study. [Published online ahead of print January 17, 2018]. BMJ. doi: 10.1136/bmj.j5790.


The authors showed increased risk of opiate misuse correlating with the number of opiate prescriptions refilled post-surgery. Now what? Health systems can’t wait for evolving guidelines. Local health system boards should demand accountable leaders and committees. The scope of their work—a redesign of the surgical experience from: 1) decision surgery is necessary (to enable appropriate patient education), to 2) inpatient care that utilizes order sets/pathways with multimodal pain management, to 3) postoperative care and follow up visit standardization. A clear opportunity is to accelerate use of Early Recovery After Surgery (ERAS)—shown to produce safe care, decreased lengths of stay, and better patient experience. Organizations are accountable to many quality metrics. In the absence of NQF measures for “opiate use post-surgery” local health systems will be forced to define internal measures of their progress in the goal of minimizing the use of opiates post-surgery. Our patients can’t wait. — Doron Schneider, MD, FACP