From April 2020 through April 2021, 75,673 Americans died from opioid overdoses. Nearly one quarter of the deaths directly involved prescription opioids.1  This represents the first time mortality has exceeded 75,000 in a 12-month period. Moreover, many people who abuse heroin and fentanyl begin opioid use with a prescription pill.2  Both the lay and academic presses have focused considerable attention on the misuse and abuse of opioid medications. However, many anesthesiologists may not understand the role perioperative anesthesia practice and pain medicine can play in addressing this issue. In this review, we summarize current evidence related to perioperative opioid administration. We also make suggestions for how anesthesiologists can reduce opioid-related harm and bring value to their healthcare systems. Finally, we provide some caveats to these suggestions given existing gaps in research and highlight areas for future research.

New Persistent Postoperative Opioid Use and Opioid Use Disorder

Substantial rates of persistent postoperative opioid prescribing in previously opioid-naïve patients have been identified in nearly every surgical cohort,3–6  albeit with highly variable definitions of this phenomenon.7  For example, 7.7% of patients older than 65 yr undergoing minor surgery continue being prescribed opioids during the first postoperative year,4  while 3.1% of patients undergoing cardiac, thoracic, intraabdominal, and pelvic surgeries have an opioid prescription dispensed 90 days or more postoperatively.3  Other investigators have identified rates of 2.2% at 6 months in retrospective data encompassing 1.35 million patients undergoing any type of in-hospital surgery,8,9  4.3 to 8.3% for prospectively collected, self-reported opioid use 6 months after total knee and hip arthroplasty,10  approximately 6% for an opioid prescription received 90 to 180 days after a variety of major and minor surgeries,6  and—perhaps most alarmingly—4.8% for an opioid prescription received during the 90 to 180 days after common pediatric surgeries.11 

Traditionally, opioids have been a mainstay of treatment for postoperative acute pain and have been prescribed with the assumption that patients will cease use once postoperative pain resolves. However, patients typically stop opioid use long before pain cessation occurs.12,13  Studies have shown that among those with persistent opioid use, surgeons are rarely the prescribers more than 3 months after surgery.14  While some of the persistent opioid prescribing could be due to nonsurgical issues,15  claims data studies using nonsurgical control cohorts found much higher rates among those undergoing surgery, suggesting surgery and postoperative prescribing as the triggering event.5,6  Some of the persistent opioid prescribing would also be expected to be attributable to new chronic postsurgical pain, but studies have shown similar prescribing rates after both major and minor surgery6  and no association with change in self-reported pain after joint arthroplasty.10  Thus, the driving factors for postoperative opioid consumption may extend beyond postoperative pain intensity and the direct treatment of surgical pain to encompass misuse for preexisting pain conditions, sleep, anxiety, and other patient-level factors (see “Preoperative Considerations” section).

It is important to note that significant data heterogeneity exists regarding new persistent postoperative opioid use incidence. Much of this variance appears to depend on the stringency of the definition used and the cohort evaluated: studies of new persistent postoperative opioid use have observed incidence of this condition ranging from 0.01 to 14.7%.7,16  While there are prospective studies showing rates of 4 to 8% after surgery,17  gaining a deeper understanding of the association between chronic postoperative opioid use and these negative opioid-related outcomes will likely require moving beyond examining administrative claims and electronic health record data through which prescribing and consumption cannot be distinguished into large longitudinal cohorts of individual patients. This approach would also permit more granular study of opioid consumption rather than prescribing or prescription fills.16  Some working groups have suggested definitions for persistent opioid use18 ; however, the cutoffs suggested are subject to similar critique as the more commonly published definitions and potentially offer greater specificity at the cost of lower sensitivity. Consensus definitions need to account for the data source (prospective, administrative, or prescription fulfillment data) and preoperative opioid status. Planned sensitivity analyses testing multiple definitions would allow for comparisons between studies and avoid the challenges of a “consensus” definition by a given group.

It is important to recognize that persistent opioid use is not synonymous with opioid use disorder (the diagnostic term for addiction), and that further research is needed to characterize the prevalence of opioid use disorder directly resulting from persistent postoperative opioid use. Similar research is needed to characterize the prevalence of postoperative opioid misuse and its relation to persistent postoperative opioid use. One obstacle to such research is that opioid use disorder is generally underrecognized and frequently goes undocumented in the electronic health record, where this diagnosis is seen much less frequently compared with the true prevalence of the condition.7,19–22  The undercounting of patients with opioid use disorder or misuse may be particularly salient to surgical patients, in whom opioid misuse rates more than seven times greater than the general population have been reported (albeit in a cohort of joint reconstruction and spine patients in whom opioid use is more common).23 

Among opioid-naïve patients presenting for surgery, increasing numbers of refills and the duration of postoperative opioid use are strongly associated with the development of opioid misuse,24  and prescribing smaller amounts of opioids after surgery and limiting refills in the context of optimized perioperative pain management are warranted. However, the causality of this relationship has not been established; it may be due to patient-level factors, such as preoperative pain, sleep, and mood, rather than opioid consumption itself. Additionally, care must be taken to avoid stigmatizing particular populations based on racial, ethnic, and sociodemographic factors. To decrease the potential for this, patients can be assessed preoperatively for risk for substance use disorder in a standardized, high-throughput manner and referred for specialized addiction medicine evaluation, if indicated.

Persistent Postoperative Opioid Use Is More Common in Preoperative Opioid Users

Not surprisingly, preoperative opioid use is associated with longer durations of postoperative opioid prescribing, more refills after surgery, and increased postoperative daily oral morphine equivalent consumption.25,26  It is also a clear risk factor for chronic postoperative opioid use.10,27–31  Between 64 and 77% of chronic opioid users before surgery continue to fill opioids postoperatively.28,29  This is particularly concerning in the context of surgery performed to address chronic pain, as there may be an expectation that opioid consumption will cease after surgery. In a prospectively collected cohort of patients undergoing arthroplasty who reported opioid use preoperatively, those reporting preoperative opioid use for another pain complaint beyond their knee or hip pain had an adjusted 2.4 times increased odds of self-reported opioid use 3 months after arthroplasty.32  Additionally, higher preoperative opioid doses and longer duration of preoperative use lead to increased risk of chronic use and continued opioid prescription fulfillment postoperatively.10,33  Most concerning is the association of preoperative opioid prescription fulfillment with increased mortality,34  morbidity, and postoperative healthcare utilization.35,36  These mortality and morbidity findings may be related to increased infectious risk secondary to opioid-induced immunosuppression.37  Given that more than 20% of patients presenting for elective surgery are already prescribed opioids,38  evidence-based interventions, prescribing guidelines, and policies should be developed for these patients that are distinct from those for opioid-naïve patients as their expected trajectories of postoperative opioid use likely differ.

Excess Opioid Prescribing

Excessive postsurgical opioid prescribing can result in a surplus of medications, increasing the possibility of diversion and misuse.39,40  Surgeons’ share of first-start opioid prescriptions to opioid-naïve patients increased more than 18% from 2010 to 2016, likely as a result of the increasing attention paid to opioid prescribing by primary care physicians.41  A 2017 study of opioid prescribing after five outpatient surgeries revealed wide variation in the number of pills prescribed for the same surgery39 ; overall, surgical patients included in a 2017 systematic review took only 29 to 58% of prescribed opioid pills.40 

The issue of perioperative opioid overprescribing has substantial societal consequences. Among U.S. adults reporting opioid misuse or opioid use disorder in 2015, 36% obtained the opioids for their most recent misuse from their own prescription, and 47% from a friend or relative’s prescription.20  This brings into focus the need for strategies such as storage education42  and home disposal kits43  to decrease opioid diversion.

While excess prescribing of opioids is a societal concern, untreated postsurgical pain and the acute to subacute to chronic pain transition represent major unmet needs for further research.44,45  A recent systematic review and meta-analysis in this journal emphasized the lack of high-quality evidence available regarding pharmacotherapy for the prevention of these conditions.46  Advancements in personalized perioperative pain care may enable identification of suboptimal pain trajectories and preemptive treatment of patients at risk for development of chronic postsurgical pain; the large-scale National Institutes of Health Common Fund–supported Acute to Chronic Pain Signatures network (http://a2cps.org/) aims to address this research need.47–50  Simpler acute pain descriptors may also prove helpful: Pain intensity predicts remote pain resolution, opioid cessation, and patient-reported surgical recovery when assessed 10 days after both major and minor operations conducted under either general or local anesthesia.49,51  However, it is noteworthy that decades of excess postdischarge opioid prescribing demonstrate that liberal opioid administration is unlikely to address the issue of persistent postsurgical pain. Furthermore, multiple studies have shown little or no association between pain scores and the amount of opioid prescribed after surgery. This suggests that for the majority of patients who undergo surgery, conservative opioid prescribing can reduce the overall excess of unused prescription opioids without worsening postoperative pain-related outcomes.52–56  While there are likely some surgeries for which opioids do not need to be prescribed routinely, they remain a cornerstone of acute postoperative pain management. Anecdotal reports of surgeons refusing to prescribe opioids based on institutional pressures or misapplication of state and federal policies and guidelines are concerning. It is critical that anesthesiologists and surgeons continue to attend to the pain needs of patients with opioids as appropriate.

While many anesthesiologists in the United States may feel disconnected from postsurgical opioid prescribing and pain management, it is important to recognize that anesthesiologists in other countries, including Australia and many European countries, are responsible for postdischarge prescribing.57,58  Moreover, given the increased interest in transitional pain services and the perioperative surgical home in the United States and Canada,59–62  the role of anesthesiologists in prescribing opioids, identifying risk, and counseling patients on safe use, storage, and disposal is likely to grow in the coming years.

Identify Patients at Risk for Persistent Postoperative Opioid Use or Misuse

The first practical step anesthesiologists can take is to identify patients at risk for postoperative persistent opioid use or misuse. Investigators have identified several risk factors for prolonged opioid use or opioid misuse (fig. 1). Those of potential relevance to anesthesiologists conducting perioperative evaluations include current opioid use,11,63–65  previous history of opioid use,66,67  current or previous substance use disorder,11,56,66,68–75  smoking,56,71,76,77  coexisting psychiatric disease (particularly anxiety and depression),30,33,56,65–68,70,73,74,77–81  more medical comorbidities (higher Elixhauser comorbidity index),77  history of chronic pain,11,69,71,82,83  and younger age.64,66,67,69,70,77  Conflicting evidence exists for sex,11,64–68,75,77  although studies focused on perioperative prescribing have identified female sex as a risk factor for persistent postoperative opioid use consistent with studies of chronic pain conditions.

Fig. 1.

Risk factors for persistent postoperative opioid use.

Fig. 1.

Risk factors for persistent postoperative opioid use.

Close modal

What to Do Once You Have Identified Patients at Risk

Set Expectations

Anesthesiologists can play a key role in setting patient expectations for pain management during the perioperative period. Doing so may help mitigate risk for postoperative opioid use and subsequent persistent use and misuse. For example, a systematic review incorporating 3,523 surgical patients found that lower expectations of postoperative pain correlated with lower actual postoperative pain in 8 of 13 identified studies.84  However, patients with erroneous expectations that they should have no or minimal pain in the postoperative period may request or consume more opioids if their pain is greater than anticipated. Between 10 and 36% of postoperative patients expect complete analgesia from pain medication,85–87  which is inconsistent with normal postoperative recovery and represents an unreasonable expectation of the efficacy of opioids. A brief conversation in the preoperative holding area to set appropriate expectations for postoperative acute pain (e.g., “You will have pain after surgery. You will receive medication for your pain, but it is not likely to take away all of your pain.”) may be feasible for anesthesiologists in every practice setting. Further research is warranted into whether this is particularly beneficial for patients having surgeries with high incidences of postoperative acute pain such as spine or thoracic surgery.

Coordinate Transitions of Care

Most preoperative chronic opioid users have a “usual prescriber,” and a return visit within 30 days of surgery with the usual prescriber is associated with decreased odds of high-risk opioid prescribing (multiple prescribers, co-prescribing of benzodiazepines, high-dose opioid prescriptions, and new long-acting prescriptions). Those without a usual prescriber also show more high-risk prescribing postoperatively. While these data are derived from an administrative claims database rather than a longitudinal cohort,88  the concept of engaging the usual prescriber in the perioperative course is consistent with the spirit of a transitional pain service.59–62  Consequently, elective surgical patients with preexisting pain or substance use disorders but without pain or addiction medicine specialists can be referred to establish care that can continue through the phases of perioperative care. Anesthesiology groups with dedicated preoperative evaluation and acute pain services are well positioned to coordinate this care; otherwise, operating room anesthesiologists can communicate these concerns to the surgical service.

Patients with chronic pain and those at risk for the development of chronic pain postoperatively may also benefit from care at a specialized transitional pain clinic before surgery.59–62  Pain physicians at these centers evaluate such patients preoperatively, help manage expectations regarding postoperative pain control, and make recommendations to anesthesiologists and surgeons about intraoperative and immediate postoperative pain management, including postdischarge tapering plans.89,90  After discharge, patients continue to be followed in the clinic in order to ensure that acute and subacute pain are managed appropriately, and to minimize the risk of transitioning to new chronic pain or exacerbating extant chronic pain. Managing these at-risk patients properly with nonopioid medications, interventional techniques, and psychologic counseling has been hypothesized to lessen their chances of developing harmful postoperative opioid use patterns.91  While there are some early descriptions of pre-post data suggesting decreased postoperative opioid consumption for both opioid-naïve and -tolerant patients after implementational of transitional pain services,59,92  we lack high-quality data on the efficacy and cost-effectiveness of transitional pain clinics. One thoughtful viewpoint examines the business case for such clinics.93  In their absence, anesthesiologists can encourage referrals to a pain medicine specialist or engaged primary care provider for potentially challenging patients.

Optimization of Preoperative Opioid Use

Opioid Tapering and Cessation

About 20% of patients presenting for surgery use opioids preoperatively, with frequency and dose varying with the type of surgery.38  Given concerns that preoperative opioid use may increase postoperative morbidity and healthcare utilization, there has been increased attention paid to preoperative opioid weaning and cessation programs. There is particular interest in weaning patients using high doses preoperatively, generally defined as greater than 90 oral morphine equivalents daily.94 

A proposed template for such a high-dose opioid taper program involves regular clinic visits over a 10- to 12-week period to assist with both opioid dose reduction and palliation of withdrawal symptoms. Participating patients have their opioid doses weaned by approximately 10% weekly if tolerated.95  While clinical discretion is needed and care should be tailored to the individual, we have provided a sample weaning protocol for a hypothetical patient (table 1). Preliminary studies suggest these programs may improve postoperative outcomes. A retrospective matched cohort study comparing 123 total knee or hip arthroplasty patients divided into three equal groups (opioid-dependent patients who weaned their dose by 50% or more preoperatively, opioid-dependent patients who did not wean their dose, and opioid-naïve controls) found that the weaned group and the opioid-naïve group had improvements in pain and functional outcomes (Western Ontario and McMaster Universities Osteoarthritis Index, University of California, Los Angeles activity score, and Short Form 12 version 2 Physical Component Score) that were significantly larger than those of the nonweaned group. Of note, the weaned group improved to a similar degree as the opioid-naïve group but did not reach the same absolute level of function because patients on opioids preoperatively had lower baseline scores. Furthermore, preoperative opioid use was self-reported by patients.97  Given the resources and time required, further study is needed to ensure preoperative weaning will improve outcomes before such care becomes a standard of care. Moreover, lengthy opioid weaning programs require close coordination with surgeons, who may hesitate to delay surgery for a 2- to 3-month wean. An additional potential consideration is that large-scale observational data have identified an association between cessation of opioid therapy and overdose or suicide, although these data are not limited to preoperative weans.98,99  Patients and caregivers can be engaged in the decision to wean after explanation of the potential benefits.100  Continued monitoring and support of patients may be warranted in the context of opioid cessation whether it occurs before or after the operation.

Table 1.

Sample Preoperative Opioid Tapering Protocol for a Patient Taking 150 mg Daily Oral Morphine Equivalents of Oxycodone (Conversion to Oral Morphine 1:1.5)

Sample Preoperative Opioid Tapering Protocol for a Patient Taking 150 mg Daily Oral Morphine Equivalents of Oxycodone (Conversion to Oral Morphine 1:1.5)
Sample Preoperative Opioid Tapering Protocol for a Patient Taking 150 mg Daily Oral Morphine Equivalents of Oxycodone (Conversion to Oral Morphine 1:1.5)

Opioid Administration during Anesthesia Care

Can anesthesia care modify susceptibility to opioid-related harm, including new chronic opioid use and opioid misuse? Some groups have suggested that “opioid-free anesthesia” should be standard of care, but the definition of this concept and the rationale for avoidance of intraoperative opioids remain unclear. Furthermore, opioid-free anesthesia practice may not be feasible for all case types, and the hemodynamic consequences of such an approach have not been evaluated (for example, some anesthesiologists utilize opioids to blunt the sympathetic response to direct laryngoscopy). Currently, there is no evidence that total avoidance of opioids during anesthesia improves outcomes other than postoperative nausea and vomiting. A meta-analysis comparing opioid-inclusive with opioid-free intraoperative anesthesia found no differences in pain scores or opioid consumption at 2, 12, or 24 h postoperatively.101  This meta-analysis did show, however, that opioids increase rates of nausea and vomiting. More recently, a multicenter randomized blinded trial of a standard balanced anesthesia technique plus remifentanil and morphine compared with the same balanced technique plus dexmedetomidine (opioid-free) was halted prematurely due to increased incidence of severe bradycardia in the opioid-free group. The primary outcome of postoperative hypoxemia, ileus, or cognitive dysfunction occurred more frequently in patients in the opioid-free group compared with the opioid-receiving group.102  In terms of postdischarge opioid-related metrics, two large-scale administrative claims studies found no relationship between nerve blockade and chronic postoperative opioid use after total knee arthroplasty103  and shoulder arthroplasty,104  thereby suggesting that simple regional anesthesia techniques alone cannot prevent poor outcomes.

There is evidence that regional anesthesia and multimodal analgesic techniques improve acute pain and reduce in-hospital opioid consumption.105  However, there are no available studies to suggest that perioperative anesthesia practices can affect long-term opioid outcomes, and there is evidence that opioid-free anesthetic strategies may increase risk for perioperative adverse events without influencing the likelihood of persistent postoperative opioid use or preventing postoperative opioid overprescription.106–108  While anesthesiologists should be judicious, opioids remain an important tool for anesthetic care. We do note that the overall level of evidence related to opioid-free anesthesia is low, and that further research regarding the impact of intraoperative opioid use on intermediate- and long-term outcomes is needed.

Postoperative Order Sets and “Automatic” Opioid Administration

Evidence exists that in-hospital opioid use is highly associated with postdischarge opioid use.109,110  In addition, elimination of standing orders for opioids from post–cesarean section order sets has been shown to decrease postoperative opioid consumption and discharge opioid prescribing.111  Further research is warranted into whether changes in postanesthesia care unit opioid order sets can have a similar influence on postoperative opioid consumption and persistent use in other cohorts. It has been posited that limiting intraoperative opioids may lead to increased postoperative opioid use, which would be counterproductive.106  However, changes in postanesthesia care unit opioid administration in concert with changes in hospital ward and discharge opioid prescribing by surgical services represent a more attractive opportunity for anesthesiologists to improve short- and long-term opioid outcomes when compared with intraoperative opioid elimination.

Educational and Behavioral Interventions

Educational and behavioral interventions initiated or coordinated by anesthesiologists or other members of the perioperative care team provide an avenue to curb postoperative opioid use.112  For example, carpal tunnel surgery patients who reviewed a one-page sheet that (1) recommended trialing nonopioid therapy before using prescribed opioids, (2) assessed opioid abuse risk factors and current opioid prescriptions, (3) provided education on the anticipated duration of opioid consumption after surgery, and (4) set expectations that the lowest opioid dose would be prescribed exhibited significantly decreased opioid consumption (mean 1.4 pills vs. 4.2 pills) over the first 3 postoperative days compared with a group that did not receive the educational intervention, without a significant difference in pain scores.113  In another trial, arthroscopic rotator cuff repair patients randomized to an intervention group watched a 2-min narrated video and read a handout detailing the risks of opioid overuse and abuse. Overall, a statistically significant 42% reduction in opioid consumption was reported in the 3 months after surgery with no differences in pain.114  However, a third randomized trial in which total hip or knee arthroplasty patients at risk for opioid-related harms were provided brochures detailing expectations for opioid use and pain control after surgery, rationale for opioid use after surgery, postoperative opioid tapering expectations, and opioid-related adverse effects found no significant reduction in the amount of opioids dispensed in the 90 days after surgery.115  While these data are not conclusive, anesthesiologists may consider formal or informal discussions related to postoperative opioid use in the preoperative holding area.

Behavioral interventions can be delivered to guide postoperative opioid tapering. In a randomized trial of motivational interviewing and guided opioid tapering support compared to usual care alone administered to patients who had undergone total hip or knee arthroplasty, patients randomized to the intervention were instructed to decrease their total daily opioid dose by 25% every 7 days while monitoring for pain and adverse effects.116  Patients randomized to a taper experienced a 62% increase in the incidence of return to baseline opioid use after surgery (hazard ratio, 1.62; 95% CI, 1.06 to 2.46; P = 0.03), and a 53% increase in the incidence of complete postoperative opioid cessation (hazard ratio, 1.57; 95% CI, 1.01 to 2.44; P = 0.05) with no adverse effects on the duration of pain or patient-reported recovery. The intervention was delivered via phone calls weekly from 2 to 7 weeks postoperatively and then monthly up to 1 year until patient-reported opioid cessation. However, patients receiving the motivational interviewing and guided tapering support intervention required an average of only three calls, demonstrating the feasibility of future scale-up of this intervention. Future research on interventions to promote postoperative opioid cessation and opioid tapering among high-risk patients is warranted as these patients are less likely to fit into the framework of conservative opioid prescribing. The increase in use and reimbursement of telehealth amid the COVID-19 pandemic further facilitates such access for transitional pain services.117,118 

Behavioral interventions provide a promising avenue to limit postoperative opioid use and encourage postoperative opioid cessation. In a small randomized controlled clinical trial, patients assigned to a digital behavioral health intervention stopped opioids 5 days sooner without differences in self-reported pain when compared to a digital health information control group.93  However, further research is needed to develop interventions specific to those at highest risk, including those with anxiety, chronic pain, or opioid tolerance. Web- and smartphone-based interventions are attractive, as they address some of the cost and access barriers to in-person behavioral treatments.

Perioperative Management of Patients with Opioid Use Disorder

The anesthesiologist’s intersection with the opioid crisis is most apparent when encountering a patient with a history of opioid use disorder. Opioid use disorder results in substantial morbidity and mortality, including opioid-related overdoses.119  It is associated with multiple comorbidities including psychiatric diagnoses, human immunodeficiency virus, and hepatitis C.120  The prevalence of this condition is estimated to be anywhere from 0.8 to 4.6% nationwide.20,21  Given the rapidly changing landscape of treatment to address the opioid crisis, anesthesiologists should be aware of the various U.S. Food and Drug Administration (Silver Spring, Maryland)–approved opioid use disorder treatment formulations and considerations for perioperative opioid management. Currently, three medications (buprenorphine, methadone, and naltrexone) are Food and Drug Administration–approved to treat opioid use disorder in various formulations. All these treatments have demonstrated reductions in illicit opioid use and mortality, yet most patients with opioid use disorder do not receive any of them.121–128 

Acute pain management in patients receiving opioid use disorder treatment can be particularly challenging given the heightened postoperative opioid requirements for pain control. However, rigorous research to inform evidence-based management is lacking, with most recommendations derived from expert opinion and case reports.129–131  Based on observational studies, continuation of buprenorphine and methadone opioid use disorder treatment after surgery may reduce supplemental opioid needs.129  Further, suboptimal pain management in patients receiving methadone may trigger disengagement from care and serious downstream effects of possible relapse, overdose, or suicide.129,130 

Buprenorphine is a partial µ-opioid receptor agonist and antagonist at the κ- and δ-opioid receptors. Given its high affinity for the µ receptor, buprenorphine competitively displaces other µ receptor agonists and can reduce opioid binding by 80 to 95% at clinical dose ranges.132  Given these considerations, older algorithms recommended the discontinuation of buprenorphine before major surgery to allow for adequate analgesia from traditional µ agonists. However, preoperative discontinuation of buprenorphine may result in increased pain and higher opioid requirements.130  Adequate pain control has been described with concomitant use of full opioid agonists with continuation of buprenorphine treatment. Rather than complete discontinuation, buprenorphine doses may be tapered to a lower dose so that analgesia can be achieved with a full opioid agonist while maintaining treatment to minimize the risks of relapse. A potential target for buprenorphine dose reductions has been suggested as 8 to 12 mg daily of the sublingual tablet.132  Although patients receiving methadone for opioid use disorder treatment have not demonstrated an increased risk of relapse with concomitant use of other opioid analgesics, the same has not been demonstrated among patients receiving buprenorphine, and continued surveillance after surgery is warranted.132  In general, buprenorphine can be restarted 12 to 24 h after the last dose of a short-acting opioid or 24 to 48 h after the last dose of a long-acting opioid if it had been discontinued.

Methadone, a full µ-opioid receptor agonist with N-methyl-d-aspartate antagonist and serotonin and norepinephrine reuptake inhibition properties, is administered as a daily oral medication by certified specialty clinics.133–135  When prescribed for opioid use disorder treatment, patients receiving methadone are less likely to experience euphoria from heroin abuse.130  Surgical patients can be instructed to take their usual methadone dose on the day of their scheduled procedure. Additional immediate-release opioids may be prescribed for the acute pain. Given the heightened risk of relapse, discontinuation of methadone is not generally recommended.130 

Naltrexone is approved by the U.S. Food and Drug Administration for the treatment of both opioid use disorder and alcohol use disorder and acts as a competitive opioid antagonist at the µ-opioid receptor.130  The oral formulation was found to be no more effective than placebo but continues to be prescribed more frequently than the injectable formulation. This medication blocks the euphoria, analgesia, and sedation from opioid agonists. Some authors have suggested discontinuing naltrexone preoperatively with the last dose 2 to 3 days before surgery for the oral formulation, and 30 days before surgery for the injectable extended release formulation.130  Before restarting naltrexone after surgery, patients should not be taking opioid agonists for at least 7 to 10 days, as this will precipitate acute opioid withdrawal if administered to a patient actively using opioids. In the event that preoperative naltrexone discontinuation is not feasible (e.g., emergency surgery), nonopioid analgesics, nonpharmacologic treatment, and regional anesthetic techniques can be considered.130  For surgeries in which opioids will not be required or can be avoided for perioperative care, there is no need to alter the naltrexone management. Of note, new longer-acting formulations of naltrexone are being trialed that would make such care coordination nearly impossible. Close communication with the patient’s addiction specialist and surgeon will be required in such a situation.

Regardless of the perioperative management strategy chosen for opioid use disorder treatment, all patients receiving such therapy can be considered for perioperative multimodal analgesia, regional anesthesia techniques, and specialist referrals when needed (addiction medicine, psychiatry, and pain medicine). The patient’s addiction provider should be engaged in all decision-making, and patients and their families must understand the plan and be engaged in decision-making. Discharge planning should include a clear transition plan back to the maintenance treatment.

Influencing Surgeon Prescribing Practices

Opioids

Anesthesiologists can serve as a resource for surgical colleagues regarding postdischarge prescribing. Multiple studies have demonstrated that the amount of opioid prescribed can be greatly reduced from traditional norms without adversely impacting patient-reported pain, satisfaction, or refill requests.54,56,109  While early analyses show that policy interventions have not led to meaningful decreases in opioid prescriptions,136,137  the implementation of surgery-specific prescribing recommendations offers more promise.55,138,139  To facilitate this, opioid prescribing guidelines for many common surgeries are available at www.opioidprescribing.info, along with specific counseling recommendations such as setting expectations; encouraging nonopioid pain medication use; and describing adverse effects, appropriate versus inappropriate use, and safe disposal.140  These evidence-based prescribing recommendations from the Opioid Prescribing Engagement Network at the University of Michigan (Ann Arbor, Michigan) were created from patient-reported outcomes from health systems throughout the state of Michigan. Implementation of these recommendations in a cohort of more than 11,000 patients across 43 centers led to a significant decrease in postdischarge opioid prescribing without increases in pain or reduction in satisfaction.55  These recommendations are updated approximately three times per year based on new data; postsurgical prescribing recommendations are also available from other large academic centers (e.g., Johns Hopkins Medicine [Baltimore, Maryland] and the Mayo Clinic [Rochester, Minnesota]).141,142  Ensuring that our surgical colleagues are aware of prescribing recommendations should be considered part of anesthesiologists’ roles as complete perioperative physicians. As noted in the section “Excess Opioid Prescribing,” postsurgical prescribing by anesthesiologists is the norm in several other countries.

Naloxone

Naloxone, an opioid receptor antagonist, has been shown to be effective in treating opioid overdose when administered in intravenous, intramuscular, and intranasal forms.143  Naloxone prescribing increased nationally between 2014 to 2017, but only approximately 2% of patients with risk factors for opioid-related overdose received a naloxone prescription.144  While these data were not specific to perioperative care, one can assume the rates of postoperative prescribing of naloxone were the same or lower. Costs between the different formulations and delivery systems vary widely.145  Most recommend intranasal formulations of naloxone given higher patient acceptance compared to injectable formulations. Anesthesiologists should assist in identifying patients with risk factors for opioid overdose such as obesity and co-prescribed benzodiazepines.146,147  Given that evaluation for these risk factors is a routine part of the preoperative evaluation, anesthesiologists are well placed to identify patients who would benefit from naloxone prescription and communicate this to surgeons.

Conclusions

Anesthesiologists have a unique opportunity to show value in the healthcare system by positively impacting the devastating opioid epidemic. A wide variety of surgeries have been linked with excess opioid prescribing and the development of new persistent postoperative opioid use. Although continued research is required to clarify the relationship between perioperative opioid use and concrete opioid-related harms, there are several practical steps anesthesiologists can take to improved acute and chronic postoperative outcomes. Furthermore, there is a pressing need to develop a personalized approach to perioperative opioid-related risk stratification, management, and the prevention of persistent postsurgical pain.

Research Support

Dr. Larach receives institutional/departmental funding for research. Dr. Hah receives funding for research from the National Institutes of Health (Bethesda, Maryland) National Institute on Drug Abuse (R01DA045027). Dr. Brummett receives funding for research from the National Institutes of Health National Institute on Drug Abuse (R01DA042859), the National Institutes of Health Common Fund (UM1NS118922), the National Institutes of Health National Institute of Arthritis and Musculoskeletal and Skin Diseases (P50AR070600), the Michigan Department of Health and Human Services (Lansing, Michigan), and the Substance Abuse and Mental Health Services Administration (Rockville, Maryland). No funder or sponsor had any role in the design, preparation, review, or approval of the manuscript.

Competing Interests

Dr. Brummett is a consultant for Heron Therapeutics (San Diego, California), Vertex Pharmaceuticals (Boston, Massachusetts), Alosa Health (Boston, Massachusetts), and the Benter Foundation (Pittsburgh, Pennsylvania), and he provides expert medical testimony. Dr. Hah is a consultant for Nalu Medical (Carlsbad, California) and SPR Therapeutics (Cleveland, Ohio). Dr. Larach declares no competing interests.

1.
Ahmad
F
,
Rossen
L
,
Sutton
P
:
Provisional drug overdose death counts.
National Center for Health Statistics
2021
.
Available at: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed December 1, 2021.
2.
Compton
WM
,
Jones
CM
,
Baldwin
GT
:
Relationship between nonmedical prescription-opioid use and heroin use.
N Engl J Med
.
2016
;
374
:
154
63
3.
Clarke
H
,
Soneji
N
,
Ko
DT
,
Yun
L
,
Wijeysundera
DN
:
Rates and risk factors for prolonged opioid use after major surgery: Population based cohort study.
BMJ
.
2014
;
348
:
g1251
4.
Alam
A
,
Gomes
T
,
Zheng
H
,
Mamdani
MM
,
Juurlink
DN
,
Bell
CM
:
Long-term analgesic use after low-risk surgery: A retrospective cohort study.
Arch Intern Med
.
2012
;
172
:
425
30
5.
Sun
EC
,
Darnall
BD
,
Baker
LC
,
Mackey
S
:
Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period.
JAMA Intern Med
.
2016
;
176
:
1286
93
6.
Brummett
CM
,
Waljee
JF
,
Goesling
J
,
Moser
S
,
Lin
P
,
Englesbe
MJ
,
Bohnert
ASB
,
Kheterpal
S
,
Nallamothu
BK
:
New persistent opioid use after minor and major surgical procedures in US adults.
JAMA Surg
.
2017
;
152
:
e170504
7.
Jivraj
NK
,
Raghavji
F
,
Bethell
J
,
Wijeysundera
DN
,
Ladha
KS
,
Bateman
BT
,
Neuman
MD
,
Wunsch
H
:
Persistent postoperative opioid use: A systematic literature search of definitions and population-based cohort study.
Anesthesiology
.
2020
;
132
:
1528
39
8.
Pagé
MG
,
Kudrina
I
,
Zomahoun
HTV
,
Croteau
J
,
Ziegler
D
,
Ngangue
P
,
Martin
E
,
Fortier
M
,
Boisvert
EE
,
Beaulieu
P
,
Charbonneau
C
,
Cogan
J
,
Daoust
R
,
Martel
MO
,
Néron
A
,
Richebé
P
,
Clarke
H
:
A systematic review of the relative frequency and risk factors for prolonged opioid prescription following surgery and trauma among adults.
Ann Surg
.
2020
;
271
:
845
54
9.
Pagé
MG
,
Clarke
H
,
Kudrina
I
:
Response to the comment on “Postoperative Opioid Prescribing and Pain”.
Ann Surg
.
2020
;
271
:
e125
6
10.
Goesling
J
,
Moser
SE
,
Zaidi
B
,
Hassett
AL
,
Hilliard
P
,
Hallstrom
B
,
Clauw
DJ
,
Brummett
CM
:
Trends and predictors of opioid use after total knee and total hip arthroplasty.
Pain
.
2016
;
157
:
1259
65
11.
Harbaugh
CM
,
Lee
JS
,
Hu
HM
,
McCabe
SE
,
Voepel-Lewis
T
,
Englesbe
MJ
,
Brummett
CM
,
Waljee
JF
:
Persistent opioid use among pediatric patients after surgery.
Pediatrics
.
2018
;
141
:
e20172439
12.
Hah
J
,
Mackey
SC
,
Schmidt
P
,
McCue
R
,
Humphreys
K
,
Trafton
J
,
Efron
B
,
Clay
D
,
Sharifzadeh
Y
,
Ruchelli
G
,
Goodman
S
,
Huddleston
J
,
Maloney
WJ
,
Dirbas
FM
,
Shrager
J
,
Costouros
JG
,
Curtin
C
,
Carroll
I
:
Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort: A randomized clinical trial.
JAMA Surg
.
2018
;
153
:
303
11
13.
Hah
JM
,
Hilmoe
H
,
Schmidt
P
,
McCue
R
,
Trafton
J
,
Clay
D
,
Sharifzadeh
Y
,
Ruchelli
G
,
Hernandez Boussard
T
,
Goodman
S
,
Huddleston
J
,
Maloney
WJ
,
Dirbas
FM
,
Shrager
J
,
Costouros
JG
,
Curtin
C
,
Mackey
SC
,
Carroll
I
:
Preoperative factors associated with remote postoperative pain resolution and opioid cessation in a mixed surgical cohort: Post hoc analysis of a perioperative gabapentin trial.
J Pain Res
.
2020
;
13
:
2959
70
14.
Klueh
MP
,
Hu
HM
,
Howard
RA
,
Vu
JV
,
Harbaugh
CM
,
Lagisetty
PA
,
Brummett
CM
,
Englesbe
MJ
,
Waljee
JF
,
Lee
JS
:
Transitions of care for postoperative opioid prescribing in previously opioid-naïve patients in the USA: A retrospective review.
J Gen Intern Med
.
2018
;
33
:
1685
91
15.
Callinan
CE
,
Neuman
MD
,
Lacy
KE
,
Gabison
C
,
Ashburn
MA
:
The initiation of chronic opioids: A survey of chronic pain patients.
J Pain
.
2017
;
18
:
360
5
16.
Kharasch
ED
,
Clark
JD
:
Persistent postoperative opioid use: Perception, progress, and promise.
Anesthesiology
.
2020
;
132
:1
304
6
17.
Goesling
J
,
Moser
SE
,
Zaidi
B
,
Hassett
AL
,
Hilliard
P
,
Hallstrom
B
,
Clauw
DJ
,
Brummett
CM
:
Trends and predictors of opioid use after total knee and total hip arthroplasty.
Pain
.
2016
;
157
:
1259
65
18.
Kent
ML
,
Hurley
RW
,
Oderda
GM
,
Gordon
DB
,
Sun
E
,
Mythen
M
,
Miller
TE
,
Shaw
AD
,
Gan
TJ
,
Thacker
JKM
,
McEvoy
MD
;
POQI-4 Working Group
:
American Society for Enhanced Recovery and Perioperative Quality Initiative-4 joint consensus statement on persistent postoperative opioid use: Definition, incidence, risk factors, and health care system initiatives.
Anesth Analg
.
2019
;
129
:
543
52
19.
Thiesset
HF
,
Schliep
KC
,
Stokes
SM
,
Valentin
VL
,
Gren
LH
,
Porucznik
CA
,
Huang
LC
:
Opioid misuse and dependence screening practices prior to surgery.
J Surg Res
.
2020
;
252
:
200
5
20.
Han
B
,
Compton
WM
,
Blanco
C
,
Crane
E
,
Lee
J
,
Jones
CM
:
Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health.
Ann Intern Med
.
2017
;
167
:
293
301
21.
Barocas
JA
,
White
LF
,
Wang
J
,
Walley
AY
,
LaRochelle
MR
,
Bernson
D
,
Land
T
,
Morgan
JR
,
Samet
JH
,
Linas
BP
:
Estimated prevalence of opioid use disorder in Massachusetts, 2011-2015: A capture-recapture analysis.
Am J Public Health
.
2018
;
108
:
1675
81
22.
Bobb
JF
,
Qiu
H
,
Matthews
AG
,
McCormack
J
,
Bradley
KA
:
Addressing identification bias in the design and analysis of cluster-randomized pragmatic trials: A case study.
Trials
.
2020
;
21
:
289
23.
Mason
MJ
,
Golladay
G
,
Jiranek
W
,
Cameron
B
,
Silverman
JJ
,
Zaharakis
NM
,
Plonski
P
:
Depression moderates the relationship between pain and the nonmedical use of opioid medication among adult outpatients.
J Addict Med
.
2016
;
10
:
408
13
24.
Brat
GA
,
Agniel
D
,
Beam
A
,
Yorkgitis
B
,
Bicket
M
,
Homer
M
,
Fox
KP
,
Knecht
DB
,
McMahill-Walraven
CN
,
Palmer
N
,
Kohane
I
:
Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: Retrospective cohort study.
BMJ
.
2018
;
360
:
j5790
25.
Catchpool
M
,
Knight
J
,
Young
JT
,
Clarke
P
,
Barrington
MJ
,
Choong
PFM
,
Dowsey
MM
:
Opioid use prior to elective surgery is strongly associated with persistent use following surgery: An analysis of 14 354 Medicare patients.
ANZ J Surg
.
2019
;
89
:
1410
6
26.
Waljee
JF
,
Zhong
L
,
Hou
H
,
Sears
E
,
Brummett
C
,
Chung
KC
:
The use of opioid analgesics following common upper extremity surgical procedures: A national, population-based study.
Plast Reconstr Surg
.
2016
;
137
:
355e
64e
27.
Raebel
MA
,
Newcomer
SR
,
Bayliss
EA
,
Boudreau
D
,
DeBar
L
,
Elliott
TE
,
Ahmed
AT
,
Pawloski
PA
,
Fisher
D
,
Toh
S
,
Donahoo
WT
:
Chronic opioid use emerging after bariatric surgery.
Pharmacoepidemiol Drug Saf
.
2014
;
23
:
1247
57
28.
Raebel
MA
,
Newcomer
SR
,
Reifler
LM
,
Boudreau
D
,
Elliott
TE
,
DeBar
L
,
Ahmed
A
,
Pawloski
PA
,
Fisher
D
,
Donahoo
WT
,
Bayliss
EA
:
Chronic use of opioid medications before and after bariatric surgery.
JAMA
.
2013
;
310
:
1369
76
29.
Zarling
BJ
,
Yokhana
SS
,
Herzog
DT
,
Markel
DC
:
Preoperative and postoperative opiate use by the arthroplasty patient.
J Arthroplasty
.
2016
;
31
:
2081
4
30.
Anderson
JT
,
Haas
AR
,
Percy
R
,
Woods
ST
,
Ahn
UM
,
Ahn
NU
:
Chronic opioid therapy after lumbar fusion surgery for degenerative disc disease in a workers’ compensation setting.
Spine (Phila Pa 1976)
.
2015
;
40
:
1775
84
31.
Kulshrestha
S
,
Barrantes
F
,
Samaniego
M
,
Luan
FL
:
Chronic opioid analgesic usage post-kidney transplantation and clinical outcomes.
Clin Transplant
.
2014
;
28
:
1041
6
32.
Ervin-Sikhondze
BA
,
Moser
SE
,
Pierce
J
,
Dickens
JR
,
Lagisetty
PA
,
Urquhart
AG
,
Hallstrom
BR
,
Brummett
CM
,
McAfee
J
:
Reasons for preoperative opioid use are associated with persistent use following surgery among patients undergoing total knee and hip arthroplasty.
Pain Med
.
2022
;
23
:
19
28
33.
Inacio
MC
,
Hansen
C
,
Pratt
NL
,
Graves
SE
,
Roughead
EE
:
Risk factors for persistent and new chronic opioid use in patients undergoing total hip arthroplasty: A retrospective cohort study.
BMJ Open
.
2016
;
6
:
e010664
34.
Barrantes
F
,
Luan
FL
,
Kommareddi
M
,
Alazem
K
,
Yaqub
T
,
Roth
RS
,
Sung
RS
,
Cibrik
DM
,
Song
P
,
Samaniego
M
:
A history of chronic opioid usage prior to kidney transplantation may be associated with increased mortality risk.
Kidney Int
.
2013
;
84
:
390
6
35.
Cron
DC
,
Englesbe
MJ
,
Bolton
CJ
,
Joseph
MT
,
Carrier
KL
,
Moser
SE
,
Waljee
JF
,
Hilliard
PE
,
Kheterpal
S
,
Brummett
CM
:
Preoperative opioid use is independently associated with increased costs and worse outcomes after major abdominal surgery.
Ann Surg
.
2017
;
265
:
695
701
36.
Waljee
JF
,
Cron
DC
,
Steiger
RM
,
Zhong
L
,
Englesbe
MJ
,
Brummett
CM
:
Effect of preoperative opioid exposure on healthcare utilization and expenditures following elective abdominal surgery.
Ann Surg
.
2017
;
265
:
715
21
37.
Oppeltz
RF
,
Holloway
TL
,
Covington
CJ
,
Schwacha
MG
:
The contribution of opiate analgesics to the development of infectious complications in trauma patients.
Int J Burns Trauma
.
2015
;
5
:
56
65
38.
Hilliard
PE
,
Waljee
J
,
Moser
S
,
Metz
L
,
Mathis
M
,
Goesling
J
,
Cron
D
,
Clauw
DJ
,
Englesbe
M
,
Abecasis
G
,
Brummett
CM
:
Prevalence of preoperative opioid use and characteristics associated with opioid use among patients presenting for surgery.
JAMA Surg
.
2018
;
153
:
929
37
39.
Hill
MV
,
McMahon
ML
,
Stucke
RS
,
Barth
RJ
, Jr
:
Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.
Ann Surg
.
2017
;
265
:
709
14
40.
Bicket
MC
,
Long
JJ
,
Pronovost
PJ
,
Alexander
GC
,
Wu
CL
:
Prescription opioid analgesics commonly unused after surgery: A systematic review.
JAMA Surg
.
2017
;
152
:
1066
71
41.
Larach
DB
,
Waljee
JF
,
Hu
HM
,
Lee
JS
,
Nalliah
R
,
Englesbe
MJ
,
Brummett
CM
:
Patterns of initial opioid prescribing to opioid-naive patients.
Ann Surg
.
2020
;
271
:
290
5
42.
Sloss
KR
,
Vargas
G
,
Brummett
CM
,
Englesbe
MJ
,
Waljee
JF
,
Gadepalli
S
,
Harbaugh
C
:
Association of caregiver-reported education with locked storage and disposal of prescription opioids after children’s surgery.
J Pediatr Surg
.
2020
;
55
:
2442
7
43.
Stokes
SM
,
Kim
RY
,
Jacobs
A
,
Esplin
J
,
Kwok
AC
,
Varghese
TK
, Jr
,
Glasgow
RE
,
Brooke
BS
,
Finlayson
SRG
,
Huang
LC
:
Home disposal kits for leftover opioid medications after surgery: Do they work?
J Surg Res
.
2020
;
245
:
396
402
44.
Gan
TJ
:
Poorly controlled postoperative pain: Prevalence, consequences, and prevention.
J Pain Res
.
2017
;
10
:
2287
98
45.
Glare
P
,
Aubrey
KR
,
Myles
PS
:
Transition from acute to chronic pain after surgery.
Lancet
.
2019
;
393
:
1537
46
46.
Carley
ME
,
Chaparro
LE
,
Choinière
M
,
Kehlet
H
,
Moore
RA
,
Van Den Kerkhof
E
,
Gilron
I
:
Pharmacotherapy for the prevention of chronic pain after surgery in adults: An updated systematic review and Meta-analysis.
Anesthesiology
.
2021
;
135
:
304
25
47.
Liu
CW
,
Page
MG
,
Weinrib
A
,
Wong
D
,
Huang
A
,
McRae
K
,
Fiorellino
J
,
Tamir
D
,
Kahn
M
,
Katznelson
R
,
Ladha
K
,
Abdallah
F
,
Cypel
M
,
Yasufuku
K
,
Chan
V
,
Parry
M
,
Khan
J
,
Katz
J
,
Clarke
H
:
Predictors of one year chronic post-surgical pain trajectories following thoracic surgery.
J Anesth
.
2021
;
35
:
505
14
48.
Vasilopoulos
T
,
Wardhan
R
,
Rashidi
P
,
Fillingim
RB
,
Wallace
MR
,
Crispen
PL
,
Parvataneni
HK
,
Prieto
HA
,
Machuca
TN
,
Hughes
SJ
,
Murad
GJA
,
Tighe
PJ
;
Temporal Postoperative Pain Signatures (TEMPOS) Group
:
Patient and procedural determinants of postoperative pain trajectories.
Anesthesiology
.
2021
;
134
:
421
34
49.
Hah
JM
,
Cramer
E
,
Hilmoe
H
,
Schmidt
P
,
McCue
R
,
Trafton
J
,
Clay
D
,
Sharifzadeh
Y
,
Ruchelli
G
,
Goodman
S
,
Huddleston
J
,
Maloney
WJ
,
Dirbas
FM
,
Shrager
J
,
Costouros
JG
,
Curtin
C
,
Mackey
SC
,
Carroll
I
:
Factors associated with acute pain estimation, postoperative pain resolution, opioid cessation, and recovery: Secondary analysis of a randomized clinical trial.
JAMA Netw Open
.
2019
;
2
:
e190168
50.
Tighe
PJ
,
Le-Wendling
LT
,
Patel
A
,
Zou
B
,
Fillingim
RB
:
Clinically derived early postoperative pain trajectories differ by age, sex, and type of surgery.
Pain
.
2015
;
156
:
609
17
51.
Hah
JM
,
Nwaneshiudu
CA
,
Cramer
EM
,
Carroll
IR
,
Curtin
CM
:
Acute pain predictors of remote postoperative pain resolution after hand surgery.
Pain Ther
.
2021
;
10
:
1105
19
52.
Howard
R
,
Waljee
J
,
Brummett
C
,
Englesbe
M
,
Lee
J
:
Reduction in opioid prescribing through evidence-based prescribing guidelines.
JAMA Surg
.
2018
;
153
:
285
7
53.
Bateman
BT
,
Cole
NM
,
Maeda
A
,
Burns
SM
,
Houle
TT
,
Huybrechts
KF
,
Clancy
CR
,
Hopp
SB
,
Ecker
JL
,
Ende
H
,
Grewe
K
,
Raposo Corradini
B
,
Schoenfeld
RE
,
Sankar
K
,
Day
LJ
,
Harris
L
,
Booth
JL
,
Flood
P
,
Bauer
ME
,
Tsen
LC
,
Landau
R
,
Leffert
LR
:
Patterns of opioid prescription and use after cesarean delivery.
Obstet Gynecol
.
2017
;
130
:
29
35
54.
Lee
JS
,
Hu
HM
,
Brummett
CM
,
Syrjamaki
JD
,
Dupree
JM
,
Englesbe
MJ
,
Waljee
JF
:
Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems Survey.
JAMA
.
2017
;
317
:
2013
5
55.
Vu
JV
,
Howard
RA
,
Gunaseelan
V
,
Brummett
CM
,
Waljee
JF
,
Englesbe
MJ
:
Statewide implementation of postoperative opioid prescribing guidelines.
N Engl J Med
.
2019
;
381
:
680
2
56.
Sekhri
S
,
Arora
NS
,
Cottrell
H
,
Baerg
T
,
Duncan
A
,
Hu
HM
,
Englesbe
MJ
,
Brummett
C
,
Waljee
JF
:
Probability of opioid prescription refilling after surgery: Does initial prescription dose matter?
Ann Surg
.
2018
;
268
:
271
6
57.
Lux
EA
,
Stamer
U
,
Meissner
W
,
Wiebalck
A
:
[Postoperative pain management after ambulatory surgery. A survey of anaesthesiologists].
Schmerz
.
2011
;
25
:
191
4
,
197
8
58.
Allen
ML
,
Leslie
K
,
Parker
AV
,
Kim
CC
,
Brooks
SL
,
Braat
S
,
Schug
SA
,
Story
DA
:
Post-surgical opioid stewardship programs across Australia and New Zealand: Current situation and future directions.
Anaesth Intensive Care
.
2019
;
47
:
548
52
59.
Mikhaeil
J
,
Ayoo
K
,
Clarke
H
,
Wąsowicz
M
,
Huang
A
:
Review of the Transitional Pain Service as a method of postoperative opioid weaning and a service aimed at minimizing the risk of chronic post-surgical pain.
Anaesthesiol Intensive Ther
.
2020
;
52
:
148
53
60.
Chou
R
,
Gordon
DB
,
de Leon-Casasola
OA
,
Rosenberg
JM
,
Bickler
S
,
Brennan
T
,
Carter
T
,
Cassidy
CL
,
Chittenden
EH
,
Degenhardt
E
,
Griffith
S
,
Manworren
R
,
McCarberg
B
,
Montgomery
R
,
Murphy
J
,
Perkal
MF
,
Suresh
S
,
Sluka
K
,
Strassels
S
,
Thirlby
R
,
Viscusi
E
,
Walco
GA
,
Warner
L
,
Weisman
SJ
,
Wu
CL
:
Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council.
J Pain
.
2016
;
17
:
131
57
61.
Soffin
EM
,
Lee
BH
,
Kumar
KK
,
Wu
CL
:
The prescription opioid crisis: Role of the anaesthesiologist in reducing opioid use and misuse.
Br J Anaesth
.
2019
;
122
:
e198
208
62.
Katz
J
,
Weinrib
A
,
Fashler
SR
,
Katznelzon
R
,
Shah
BR
,
Ladak
SS
,
Jiang
J
,
Li
Q
,
McMillan
K
,
Santa Mina
D
,
Wentlandt
K
,
McRae
K
,
Tamir
D
,
Lyn
S
,
de Perrot
M
,
Rao
V
,
Grant
D
,
Roche-Nagle
G
,
Cleary
SP
,
Hofer
SO
,
Gilbert
R
,
Wijeysundera
D
,
Ritvo
P
,
Janmohamed
T
,
O’Leary
G
,
Clarke
H
:
The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain.
J Pain Res
.
2015
;
8
:
695
702
63.
Daoust
R
,
Paquet
J
,
Moore
L
,
Gosselin
S
,
Gelinas
C
,
Rouleau
DM
,
Berube
M
,
Morris
J
:
Incidence and risk factors of long-term opioid use in elderly trauma patients.
Ann Surg
.
2018
;
268
:
985
91
64.
Bedard
NA
,
Pugely
AJ
,
Dowdle
SB
,
Duchman
KR
,
Glass
NA
,
Callaghan
JJ
:
Opioid use following total hip arthroplasty: Trends and risk factors for prolonged use.
J Arthroplasty
.
2017
;
32
:
3675
9
65.
Yang
S
,
Werner
BC
:
Risk factors for prolonged postoperative opioid use after spinal fusion for adolescent idiopathic scoliosis.
J Pediatr Orthop
.
2019
;
39
:
500
4
66.
Rice
JB
,
White
AG
,
Birnbaum
HG
,
Schiller
M
,
Brown
DA
,
Roland
CL
:
A model to identify patients at risk for prescription opioid abuse, dependence, and misuse.
Pain Med
.
2012
;
13
:
1162
73
67.
Cochran
BN
,
Flentje
A
,
Heck
NC
,
Van Den Bos
J
,
Perlman
D
,
Torres
J
,
Valuck
R
,
Carter
J
:
Factors predicting development of opioid use disorders among individuals who receive an initial opioid prescription: Mathematical modeling using a database of commercially-insured individuals.
Drug Alcohol Depend
.
2014
;
138
:
202
8
68.
White
AG
,
Birnbaum
HG
,
Schiller
M
,
Tang
J
,
Katz
NP
:
Analytic models to identify patients at risk for prescription opioid abuse.
Am J Manag Care
.
2009
;
15
:
897
906
69.
Sullivan
MD
,
Edlund
MJ
,
Fan
MY
,
DeVries
A
,
Braden
JB
,
Martin
BC
:
Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and Medicaid insurance plans: The TROUP study.
Pain
.
2010
;
150
:
332
9
70.
Edlund
MJ
,
Martin
BC
,
Fan
MY
,
Devries
A
,
Braden
JB
,
Sullivan
MD
:
Risks for opioid abuse and dependence among recipients of chronic opioid therapy: Results from the TROUP study.
Drug Alcohol Depend
.
2010
;
112
:
90
8
71.
Lanier
WA
,
Johnson
EM
,
Rolfs
RT
,
Friedrichs
MD
,
Grey
TC
:
Risk factors for prescription opioid-related death, Utah, 2008-2009.
Pain Med
.
2012
;
13
:
1580
9
72.
Buttram
ME
,
Kurtz
SP
,
Surratt
HL
,
Levi-Minzi
MA
:
Health and social problems associated with prescription opioid misuse among a diverse sample of substance-using MSM.
Subst Use Misuse
.
2014
;
49
:
277
84
73.
Dilokthornsakul
P
,
Moore
G
,
Campbell
JD
,
Lodge
R
,
Traugott
C
,
Zerzan
J
,
Allen
R
,
Page
RL
, II
:
Risk factors of prescription opioid overdose among Colorado Medicaid beneficiaries.
J Pain
.
2016
;
17
:
436
43
74.
Cochran
G
,
Rosen
D
,
McCarthy
RM
,
Engel
RJ
:
Risk factors for symptoms of prescription opioid misuse: Do older adults differ from younger adult patients?
J Gerontol Soc Work
.
2017
;
60
:
443
57
75.
Brady
JE
,
Giglio
R
,
Keyes
KM
,
DiMaggio
C
,
Li
G
:
Risk markers for fatal and non-fatal prescription drug overdose: A meta-analysis.
Inj Epidemiol
.
2017
;
4
:
24
76.
Zale
EL
,
Dorfman
ML
,
Hooten
WM
,
Warner
DO
,
Zvolensky
MJ
,
Ditre
JW
:
Tobacco smoking, nicotine dependence, and patterns of prescription opioid misuse: Results from a nationally representative sample.
Nicotine Tob Res
.
2015
;
17
:
1096
103
77.
Johnson
SP
,
Chung
KC
,
Zhong
L
,
Shauver
MJ
,
Engelsbe
MJ
,
Brummett
C
,
Waljee
JF
:
Risk of prolonged opioid use among opioid-naïve patients following common hand surgery procedures.
J Hand Surg Am
.
2016
;
41
:
947
957.e3
78.
Marcusa
DP
,
Mann
RA
,
Cron
DC
,
Fillinger
BR
,
Rzepecki
AK
,
Kozlow
JH
,
Momoh
A
,
Englesbe
M
,
Brummett
C
,
Waljee
JF
:
Prescription opioid use among opioid-naive women undergoing immediate breast reconstruction.
Plast Reconstr Surg
.
2017
;
140
:
1081
90
79.
Hah
JM
,
Bateman
BT
,
Ratliff
J
,
Curtin
C
,
Sun
E
:
Chronic opioid use after surgery: Implications for perioperative management in the face of the opioid epidemic.
Anesth Analg
.
2017
;
125
:
1733
40
80.
Carroll
I
,
Barelka
P
,
Wang
CK
,
Wang
BM
,
Gillespie
MJ
,
McCue
R
,
Younger
JW
,
Trafton
J
,
Humphreys
K
,
Goodman
SB
,
Dirbas
F
,
Whyte
RI
,
Donington
JS
,
Cannon
WB
,
Mackey
SC
:
A pilot cohort study of the determinants of longitudinal opioid use after surgery.
Anesth Analg
.
2012
;
115
:
694
702
81.
Larach
DB
,
Sahara
MJ
,
As-Sanie
S
,
Moser
SE
,
Urquhart
AG
,
Lin
J
,
Hassett
AL
,
Wakeford
JA
,
Clauw
DJ
,
Waljee
JF
,
Brummett
CM
:
Patient factors associated with opioid consumption in the month following major surgery.
Ann Surg
.
2021
;
273
:
507
15
82.
Whiteside
LK
,
Russo
J
,
Wang
J
,
Ranney
ML
,
Neam
V
,
Zatzick
DF
:
Predictors of sustained prescription opioid use after admission for trauma in adolescents.
J Adolesc Health
.
2016
;
58
:
92
7
83.
Blanco
C
,
Wall
MM
,
Okuda
M
,
Wang
S
,
Iza
M
,
Olfson
M
:
Pain as a predictor of opioid use disorder in a nationally representative sample.
Am J Psychiatry
.
2016
;
173
:
1189
95
84.
Waljee
J
,
McGlinn
EP
,
Sears
ED
,
Chung
KC
:
Patient expectations and patient-reported outcomes in surgery: A systematic review.
Surgery
.
2014
;
155
:
799
808
85.
Kuhn
S
,
Cooke
K
,
Collins
M
,
Jones
JM
,
Mucklow
JC
:
Perceptions of pain relief after surgery.
BMJ
.
1990
;
300
:
1687
90
86.
Svensson
I
,
Sjöström
B
,
Haljamäe
H
:
Influence of expectations and actual pain experiences on satisfaction with postoperative pain management.
Eur J Pain
.
2001
;
5
:
125
33
87.
Scott
NB
,
Hodson
M
:
Public perceptions of postoperative pain and its relief.
Anaesthesia
.
1997
;
52
:
438
42
88.
Lagisetty
P
,
Bohnert
A
,
Goesling
J
,
Hu
HM
,
Travis
B
,
Lagisetty
K
,
Brummett
CM
,
Englesbe
MJ
,
Waljee
J
:
Care coordination for patients on chronic opioid therapy following surgery: A cohort study.
Ann Surg
.
2020
;
272
:
304
10
89.
Joo
SS
,
Hunter
OO
,
Tamboli
M
,
Leng
JC
,
Harrison
TK
,
Kassab
K
,
Keeton
JD
,
Skirboll
S
,
Tharin
S
,
Saleh
E
,
Mudumbai
SC
,
Wang
RR
,
Kou
A
,
Mariano
ER
:
Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery.
Reg Anesth Pain Med
.
2020
;
45
:
474
8
90.
Tamboli
M
,
Mariano
ER
,
Gustafson
KE
,
Briones
BL
,
Hunter
OO
,
Wang
RR
,
Harrison
TK
,
Kou
A
,
Mudumbai
SC
,
Kim
TE
,
Indelli
PF
,
Giori
NJ
:
A multidisciplinary patient-specific opioid prescribing and tapering protocol is associated with a decrease in total opioid dose prescribed for six weeks after total hip arthroplasty.
Pain Med
.
2020
;
21
:
1474
81
91.
Clarke
H
,
Ladha
K
:
Time for accountability and change: Institutional gaps in pain care during the opioid crisis.
Br J Anaesth
.
2019
;
122
:
e90
3
92.
Buys
MJ
,
Bayless
K
,
Romesser
J
,
Anderson
Z
,
Patel
S
,
Zhang
C
,
Presson
AP
,
Brooke
BS
:
Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service.
Reg Anesth Pain Med
.
2020
;
45
:
847
52
93.
Sun
EC
,
Mariano
ER
,
Narouze
S
,
Gabriel
RA
,
Elsharkawy
H
,
Gulur
P
,
Merrick
SK
,
Harrison
TK
,
Clark
JD
:
Making a business plan for starting a transitional pain service within the US healthcare system.
Reg Anesth Pain Med
.
2021
;
46
:
727
31
94.
Bohnert
ASB
,
Guy
GP
, Jr
,
Losby
JL
:
Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention’s 2016 opioid guideline.
Ann Intern Med
.
2018
;
169
:
367
75
95.
McAnally
H
:
Rationale for and approach to preoperative opioid weaning: A preoperative optimization protocol.
Perioper Med (Lond)
.
2017
;
6
:
19
96.
Berna
C
,
Kulich
RJ
,
Rathmell
JP
:
Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for everyday practice.
Mayo Clin Proc
.
2015
;
90
:
828
42
97.
Nguyen
LC
,
Sing
DC
,
Bozic
KJ
:
Preoperative reduction of opioid use before total joint arthroplasty.
J Arthroplasty
.
2016
;
31
(
9 suppl
):
282
7
98.
Oliva
EM
,
Bowe
T
,
Manhapra
A
,
Kertesz
S
,
Hah
JM
,
Henderson
P
,
Robinson
A
,
Paik
M
,
Sandbrink
F
,
Gordon
AJ
,
Trafton
JA
:
Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: Observational evaluation.
BMJ
.
2020
;
368
:
m283
99.
Bohnert
ASB
,
Ilgen
MA
:
Understanding links among opioid use, overdose, and suicide.
N Engl J Med
.
2019
;
380
:
71
9
100.
Darnall
BD
,
Ziadni
MS
,
Stieg
RL
,
Mackey
IG
,
Kao
MC
,
Flood
P
:
Patient-centered prescription opioid tapering in community outpatients with chronic pain.
JAMA Intern Med
.
2018
;
178
:
707
8
101.
Frauenknecht
J
,
Kirkham
KR
,
Jacot-Guillarmod
A
,
Albrecht
E
:
Analgesic impact of intra-operative opioids versus opioid-free anaesthesia: A systematic review and meta-analysis.
Anaesthesia
.
2019
;
74
:
651
62
102.
Beloeil
H
,
Garot
M
,
Lebuffe
G
,
Gerbaud
A
,
Bila
J
,
Cuvillon
P
,
Dubout
E
,
Oger
S
,
Nadaud
J
,
Becret
A
,
Coullier
N
,
Lecoeur
S
,
Fayon
J
,
Godet
T
,
Mazerolles
M
,
Atallah
F
,
Sigaut
S
,
Choinier
P-M
,
Asehnoune
K
,
Roquilly
A
,
Chanques
G
,
Esvan
M
,
Futier
E
,
Laviolle
B
,
Group
PS
,
Network
SR
:
Balanced opioid-free anesthesia with dexmedetomidine versus balanced anesthesia with remifentanil for major or intermediate noncardiac surgery: The Postoperative and Opioid-free Anesthesia (POFA) randomized clinical trial.
Anesthesiology
.
2021
;
134
:
541
51
103.
Sun
EC
,
Bateman
BT
,
Memtsoudis
SG
,
Neuman
MD
,
Mariano
ER
,
Baker
LC
:
Lack of association between the use of nerve blockade and the risk of postoperative chronic opioid use among patients undergoing total knee arthroplasty: Evidence from the Marketscan database.
Anesth Analg
.
2017
;
125
:
999
1007
104.
Mueller
KG
,
Memtsoudis
SG
,
Mariano
ER
,
Baker
LC
,
Mackey
S
,
Sun
EC
:
Lack of association between the use of nerve blockade and the risk of persistent opioid use among patients undergoing shoulder arthroplasty: Evidence from the Marketscan database.
Anesth Analg
.
2017
;
125
:
1014
20
105.
Kumar
K
,
Kirksey
MA
,
Duong
S
,
Wu
CL
:
A review of opioid-sparing modalities in perioperative pain management: Methods to decrease opioid use postoperatively.
Anesth Analg
.
2017
;
125
:
1749
60
106.
Kharasch
ED
,
Avram
MJ
,
Clark
JD
:
Rational perioperative opioid management in the era of the opioid crisis.
Anesthesiology
.
2020
;
132
:
603
5
107.
Shanthanna
H
,
Ladha
KS
,
Kehlet
H
,
Joshi
GP
:
Perioperative opioid administration: A critical review of opioid-free versus opioid-sparing approaches.
Anesthesiology
.
2021
;
134
:
645
59
108.
Kharasch
ED
,
Clark
JD
:
Opioid-free anesthesia: Time to regain our balance.
Anesthesiology
.
2021
;
134
:
509
14
109.
Hill
MV
,
Stucke
RS
,
Billmeier
SE
,
Kelly
JL
,
Barth
RJ
, Jr
:
Guideline for discharge opioid prescriptions after inpatient general surgical procedures.
J Am Coll Surg
.
2018
;
226
:
996
1003
110.
Brescia
AA
,
Clark
MJ
,
Theurer
PF
,
Lall
SC
,
Nemeh
HW
,
Downey
RS
,
Martin
DE
,
Dabir
RR
,
Asfaw
ZE
,
Robinson
PL
,
Harrington
SD
,
Gandhi
DB
,
Waljee
JF
,
Englesbe
MJ
,
Brummett
CM
,
Prager
RL
,
Likosky
DS
,
Kim
KM
,
Lagisetty
KH
;
Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC); Michigan Opioid Prescribing Engagement Network (Michigan OPEN)
:
Establishment and implementation of evidence-based opioid prescribing guidelines in cardiac surgery.
Ann Thorac Surg
.
2021
;
112
:
1176
85
111.
Holland
E
,
Bateman
BT
,
Cole
N
,
Taggart
A
,
Robinson
LA
,
Sugrue
R
,
Xu
X
,
Robinson
JN
:
Evaluation of a quality improvement intervention that eliminated routine use of opioids after cesarean delivery.
Obstet Gynecol
.
2019
;
133
:
91
7
112.
Wetzel
M
,
Hockenberry
J
,
Raval
MV
:
Interventions for postsurgical opioid prescribing: A systematic review.
JAMA Surg
.
2018
;
153
:
948
54
113.
Alter
TH
,
Ilyas
AM
:
A prospective randomized study analyzing preoperative opioid counseling in pain management after carpal tunnel release surgery.
J Hand Surg Am
.
2017
;
42
:
810
5
114.
Syed
UAM
,
Aleem
AW
,
Wowkanech
C
,
Weekes
D
,
Freedman
M
,
Tjoumakaris
F
,
Abboud
JA
,
Austin
LS
:
Neer Award 2018: The effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: A prospective, randomized clinical trial.
J Shoulder Elbow Surg
.
2018
;
27
:
962
7
115.
Smith
DH
,
Kuntz
JL
,
DeBar
LL
,
Mesa
J
,
Yang
X
,
Schneider
J
,
Petrik
A
,
Reese
K
,
Thorsness
LA
,
Boardman
D
,
Johnson
ES
:
A randomized, pragmatic, pharmacist-led intervention reduced opioids following orthopedic surgery.
Am J Manag Care
.
2018
;
24
:
515
21
116.
Hah
JM
,
Trafton
JA
,
Narasimhan
B
,
Krishnamurthy
P
,
Hilmoe
H
,
Sharifzadeh
Y
,
Huddleston
JI
,
Amanatullah
D
,
Maloney
WJ
,
Goodman
S
,
Carroll
I
,
Mackey
SC
:
Efficacy of motivational-interviewing and guided opioid tapering support for patients undergoing orthopedic surgery (MI-Opioid Taper): A prospective, assessor-blind, randomized controlled pilot trial.
EClinicalMedicine
.
2020
;
28
:
100596
117.
Slomski
A
:
Telehealth success spurs a call for greater post-COVID-19 license portability.
JAMA
.
2020
;
324
:
1021
2
118.
Whaley
CM
,
Pera
MF
,
Cantor
J
,
Chang
J
,
Velasco
J
,
Hagg
HK
,
Sood
N
,
Bravata
DM
:
Changes in health services use among commercially insured US populations during the COVID-19 pandemic.
JAMA Netw Open
.
2020
;
3
:
e2024984
119.
Hedegaard
H
,
Warner
M
,
Minino
AM
:
Drug overdose deaths in the United States, 1999-2016.
NCHS Data Brief
.
2017
:
1
8
120.
Blanco
C
,
Volkow
ND
:
Management of opioid use disorder in the USA: Present status and future directions.
Lancet
.
2019
;
393
:
1760
72
121.
Knudsen
HK
,
Abraham
AJ
,
Roman
PM
:
Adoption and implementation of medications in addiction treatment programs.
J Addict Med
.
2011
;
5
:
21
7
122.
Jones
CM
,
Campopiano
M
,
Baldwin
G
,
McCance-Katz
E
:
National and state treatment need and capacity for opioid agonist medication-assisted treatment.
Am J Public Health
.
2015
;
105
:
e55
63
123.
Lee
JD
,
Nunes
EV
, Jr
,
Novo
P
,
Bachrach
K
,
Bailey
GL
,
Bhatt
S
,
Farkas
S
,
Fishman
M
,
Gauthier
P
,
Hodgkins
CC
,
King
J
,
Lindblad
R
,
Liu
D
,
Matthews
AG
,
May
J
,
Peavy
KM
,
Ross
S
,
Salazar
D
,
Schkolnik
P
,
Shmueli-Blumberg
D
,
Stablein
D
,
Subramaniam
G
,
Rotrosen
J
:
Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): A multicentre, open-label, randomised controlled trial.
Lancet
.
2018
;
391
:
309
18
124.
Fullerton
CA
,
Kim
M
,
Thomas
CP
,
Lyman
DR
,
Montejano
LB
,
Dougherty
RH
,
Daniels
AS
,
Ghose
SS
,
Delphin-Rittmon
ME
:
Medication-assisted treatment with methadone: Assessing the evidence.
Psychiatr Serv
.
2014
;
65
:
146
57
125.
Haight
BR
,
Learned
SM
,
Laffont
CM
,
Fudala
PJ
,
Zhao
Y
,
Garofalo
AS
,
Greenwald
MK
,
Nadipelli
VR
,
Ling
W
,
Heidbreder
C
;
RB-US-13-0001 Study Investigators
:
Efficacy and safety of a monthly buprenorphine depot injection for opioid use disorder: A multicentre, randomised, double-blind, placebo-controlled, phase 3 trial.
Lancet
.
2019
;
393
:
778
90
126.
Nasser
AF
,
Greenwald
MK
,
Vince
B
,
Fudala
PJ
,
Twumasi-Ankrah
P
,
Liu
Y
,
Jones
JP
, III
,
Heidbreder
C
:
Sustained-release buprenorphine (RBP-6000) blocks the effects of opioid challenge with hydromorphone in subjects with opioid use disorder.
J Clin Psychopharmacol
.
2016
;
36
:
18
26
127.
Rosenthal
RN
,
Lofwall
MR
,
Kim
S
,
Chen
M
,
Beebe
KL
,
Vocci
FJ
;
PRO-814 Study Group
:
Effect of buprenorphine implants on illicit opioid use among abstinent adults with opioid dependence treated with sublingual buprenorphine: A randomized clinical trial.
JAMA
.
2016
;
316
:
282
90
128.
Mattick
RP
,
Breen
C
,
Kimber
J
,
Davoli
M
:
Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.
Cochrane Database Syst Rev
.
2014
;
2
:
CD002207
129.
Veazie
S
,
Mackey
K
,
Peterson
K
,
Bourne
D
:
Managing acute pain in patients taking medication for opioid use disorder: A rapid review.
J Gen Intern Med
.
2020
;
35
(
suppl 3
):
945
53
130.
Scholzen
E
,
Zeng
AM
,
Schroeder
KM
:
Perioperative management and analgesia for patients taking buprenorphine and other forms of medication-assisted treatment for substance abuse disorders.
Adv Anesth
.
2019
;
37
:
65
86
131.
Goel
A
,
Azargive
S
,
Weissman
JS
,
Shanthanna
H
,
Hanlon
JG
,
Samman
B
,
Dominicis
M
,
Ladha
KS
,
Lamba
W
,
Duggan
S
,
Di Renna
T
,
Peng
P
,
Wong
C
,
Sinha
A
,
Eipe
N
,
Martell
D
,
Intrater
H
,
MacDougall
P
,
Kwofie
K
,
St-Jean
M
,
Rashiq
S
,
Van Camp
K
,
Flamer
D
,
Satok-Wolman
M
,
Clarke
H
:
Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: Results of a modified Delphi process.
Br J Anaesth
.
2019
;
123
:
e333
42
132.
Warner
NS
,
Warner
MA
,
Cunningham
JL
,
Gazelka
HM
,
Hooten
WM
,
Kolla
BP
,
Warner
DO
:
A practical approach for the management of the mixed opioid agonist-antagonist buprenorphine during acute pain and surgery.
Mayo Clin Proc
.
2020
;
95
:
1253
67
133.
Jarvis
BP
,
Holtyn
AF
,
Subramaniam
S
,
Tompkins
DA
,
Oga
EA
,
Bigelow
GE
,
Silverman
K
:
Extended-release injectable naltrexone for opioid use disorder: A systematic review.
Addiction
.
2018
;
113
:
1188
209
134.
Alderks
CE
:
Trends in the Use of Methadone, Buprenorphine, and Extended-release Naltrexone at Substance Abuse Treatment Facilities: 2003-2015 (Update), The CBHSQ Report
.
Rockville, Maryland
,
Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration
,
2017
135.
Sharma
A
,
Kelly
SM
,
Mitchell
SG
,
Gryczynski
J
,
O’Grady
KE
,
Schwartz
RP
:
Update on barriers to pharmacotherapy for opioid use disorders.
Curr Psychiatry Rep
.
2017
;
19
:
35
136.
Chua
KP
,
Kimmel
L
,
Brummett
CM
:
Disappointing early results from opioid prescribing limits for acute pain.
JAMA Surg
.
2020
;
155
:
375
6
137.
Agarwal
S
,
Bryan
JD
,
Hu
HM
,
Lee
JS
,
Chua
KP
,
Haffajee
RL
,
Brummett
CM
,
Englesbe
MJ
,
Waljee
JF
:
Association of state opioid duration limits with postoperative opioid prescribing.
JAMA Netw Open
.
2019
;
2
:
e1918361
138.
Howard
R
,
Fry
B
,
Gunaseelan
V
,
Lee
J
,
Waljee
J
,
Brummett
C
,
Campbell
D
, Jr
,
Seese
E
,
Englesbe
M
,
Vu
J
:
Association of opioid prescribing with opioid consumption after surgery in Michigan.
JAMA Surg
.
2019
;
154
:
e184234
139.
Brown
CS
,
Vu
JV
,
Howard
RA
,
Gunaseelan
V
,
Brummett
CM
,
Waljee
J
,
Englesbe
M
:
Assessment of a quality improvement intervention to decrease opioid prescribing in a regional health system.
BMJ Qual Saf
.
2021
;
30
:
251
9
140.
Michigan Opioid Prescribing Engagement Network: Opioid prescribing recommendations.
Available at: www.opioidprescribing.info. Accessed February 10, 2018
.
141.
Overton
HN
,
Hanna
MN
,
Bruhn
WE
,
Hutfless
S
,
Bicket
MC
,
Makary
MA
;
Opioids After Surgery Workgroup
:
Opioid-prescribing guidelines for common surgical procedures: An expert panel consensus.
J Am Coll Surg
.
2018
;
227
:
411
8
142.
Wyles
CC
,
Hevesi
M
,
Trousdale
ER
,
Ubl
DS
,
Gazelka
HM
,
Habermann
EB
,
Trousdale
RT
,
Pagnano
MW
,
Mabry
TM
:
The 2018 Chitranjan S. Ranawat, MD Award: Developing and implementing a novel institutional guideline strategy reduced postoperative opioid prescribing after TKA and THA.
Clin Orthop Relat Res
.
2019
;
477
:
104
13
143.
Kerr
D
,
Kelly
AM
,
Dietze
P
,
Jolley
D
,
Barger
B
:
Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose.
Addiction
.
2009
;
104
:
2067
74
144.
Lin
LA
,
Brummett
CM
,
Waljee
JF
,
Englesbe
MJ
,
Gunaseelan
V
,
Bohnert
ASB
:
Association of opioid overdose risk factors and naloxone prescribing in US adults.
J Gen Intern Med
.
2020
;
35
:
420
7
145.
Gupta
R
,
Shah
ND
,
Ross
JS
:
The rising price of naloxone - Risks to efforts to stem overdose deaths.
N Engl J Med
.
2016
;
375
:
2213
5
146.
Park
TW
,
Lin
LA
,
Hosanagar
A
,
Kogowski
A
,
Paige
K
,
Bohnert
AS
:
Understanding risk factors for opioid overdose in clinical populations to inform treatment and policy.
J Addict Med
.
2016
;
10
:
369
81
147.
Webster
LR
,
Cochella
S
,
Dasgupta
N
,
Fakata
KL
,
Fine
PG
,
Fishman
SM
,
Grey
T
,
Johnson
EM
,
Lee
LK
,
Passik
SD
,
Peppin
J
,
Porucznik
CA
,
Ray
A
,
Schnoll
SH
,
Stieg
RL
,
Wakeland
W
:
An analysis of the root causes for opioid-related overdose deaths in the United States.
Pain Med
.
2011
;
12
(
suppl 2
):
S26
35