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Prospective cohort study on the trajectory and association of perioperative anxiety and postoperative opioid-related outcomes
  1. Shay N Nguyen1,
  2. Afton L Hassett2,
  3. Hsou-Mei Hu3,
  4. Chad M Brummett2,
  5. Mark C Bicket2,4,
  6. Noelle E Carlozzi3,5 and
  7. Jennifer F Waljee3
  1. 1 Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
  2. 2 Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
  3. 3 Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
  4. 4 Opioid Prescribing Engagement Network (OPEN), Institute for Health Policy and Evaluations, University of Michigan, Ann Arbor, MI, USA
  5. 5 Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Jennifer F Waljee, University of Michigan Medical School, Ann Arbor, MI 48109, USA; filip{at}


Introduction Although perioperative anxiety is common, its trajectory and influence on postoperative pain and opioid use are not well understood. We sought to examine the association and trajectory of perioperative anxiety, pain and opioid use following common surgical procedures.

Methods We conducted a prospective cohort study of 1771 patients undergoing elective surgical procedures. Self-reported opioid use, pain (Brief Pain Inventory) and anxiety (Patient-Reported Outcome Measurement Information System (PROMIS) Anxiety) were recorded on the day of surgery and at 1 month, 3 months and 6 months postsurgery. Clinically significant anxiety was defined as a PROMIS Anxiety T-score ≥55. We examined postoperative opioid use in the context of surgical site pain and anxiety using mixed-effects regression models adjusted for covariates, and examined anxiety as a mediator between pain and opioid use.

Results In this cohort, 65% of participants completed all follow-ups and 30% reported clinically significant anxiety at baseline. Anxiety and surgical site pain were highest on the day of surgery (anxiety: mean=49.3, SD=9.0; pain: mean=4.3, SD=3.3) and declined in the follow-up period. Those with anxiety reported higher opioid use (OR=1.40; 95% CI 1.0, 1.9) and 1.14-point increase in patient-reported surgical pain (95% CI 1.0, 1.3) compared with those without anxiety. Anxiety had no significant mediation effect on the relationship of pain and opioid use.

Discussion Anxiety is an independent risk factor for increased pain and opioid use after surgery. Future studies examining targeted behavioral therapies to reduce anxiety during the perioperative period may positively impact postoperative pain and opioid use.

  • Analgesics, Opioid
  • Pain, Postoperative
  • Pain Management
  • Pain Perception

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @drchadb, @MarkBicket

  • Contributors SNN wrote the manuscript with support from AH and JFW. All data analysis was performed by our analyst H-MH, with tables and figures edited by SNN. All authors participated in the development of this project and edited the final version of the manuscript. JFW conceived the original idea and supervised the project, and is the author acting as guarantor.

  • Funding Dr. Waljee, Dr. Bicket, Dr. Brummett, and Dr. Carlozzi are supported by the National Institute on Drug Abuse (R01DA042859). Nguyen received financial support from the NIH (5 T35 HL 7690-37). Further support from the University of Michigan Precision Health Initiative.

  • Competing interests The authors declare no conflicts of interest. Dr. Bicket reports past service as consultant for Axial Healthcare and Alosa Health, a non-profit organization focusing on academic detailing, outside the submitted work. Dr. Brummett reports consulting activities with Heron Therapeutics, Vertex Pharmaceuticals, Alosa Health, and the Benter Foundation, as well as expert medical testimony.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.