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Perioperative opioid prescribing and iatrogenic opioid use disorder and overdose: a state-of-the-art narrative review
  1. Daniel B Larach1,
  2. Jennifer F Waljee2,
  3. Mark C Bicket3,
  4. Chad M Brummett3 and
  5. Stephen Bruehl1
  1. 1Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  2. 2Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
  3. 3Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Daniel B Larach, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA; daniel.larach{at}


Background/importance Considerable attention has been paid to identifying and mitigating perioperative opioid-related harms. However, rates of postsurgical opioid use disorder (OUD) and overdose, along with associated risk factors, have not been clearly defined.

Objective Evaluate the evidence connecting perioperative opioid prescribing with postoperative OUD and overdose, compare these data with evidence from the addiction literature, discuss the clinical impact of these conditions, and make recommendations for further study.

Evidence review State-of-the-art narrative review.

Findings Nearly all evidence is from large retrospective studies of insurance claims and Veterans Health Administration (VHA) data. Incidence rates of new OUD within the first year after surgery ranged from 0.1% to 0.8%, while rates of overdose events ranged from 0.01% to 0.8%. Higher rates were seen among VHA patients, which may reflect differences in data completeness and/or risk factors. Identified risk factors included those related to substance use (preoperative opioid use; non-opioid substance use disorders; preoperative sedative, anxiolytic, antidepressant, and gabapentinoid use; and postoperative new persistent opioid use (NPOU)); demographic attributes (chiefly male sex, younger age, white race, and Medicaid or no insurance coverage); psychiatric comorbidities such as depression, bipolar disorder, and PTSD; and certain medical and surgical factors. Several challenges related to the use of administrative claims data were identified; there is a need for more granular retrospective studies and, ideally, prospective cohorts to assess postoperative OUD and overdose incidence with greater accuracy.

Conclusions Retrospective data suggest an incidence of new postoperative OUD and overdose of up to 0.8% during the first year after surgery, but prospective studies are lacking.

  • Analgesics, Opioid
  • Opioid-Related Disorders
  • Pain Management

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  • Contributors Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; Drafting the work or reviewing it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: DBL, JFW, MCB, CMB, and SB. DBL is responsible for the overall content as guarantor, accepts full responsibility for the finished work, and controlled the decision to publish.

  • Funding DBL’s work on this manuscript was supported by the National Institute on Aging (P30AG024968), the National Institute on Drug Abuse (K23DA057387), and the National Institute of General Medical Sciences (T32GM108554). JFW was supported by the National Institute on Drug Abuse (R01DA057284). JFW, MCB, and CMB were supported by Medicaid and the Michigan Department of Health and Human Services (E20221872-00). SB was supported by the National Institute on Drug Abuse (R01DA050334).

  • Competing interests CMB serves as a consultant for Vertex Pharmaceuticals and Merck Pharmaceuticals, and provides expert medicolegal testimony. For the remaining authors, no conflicts of interest were declared.

  • 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.