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Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study

BMJ 2018; 360 doi: (Published 17 January 2018) Cite this as: BMJ 2018;360:j5790
  1. Gabriel A Brat, instructor in surgery1 2,
  2. Denis Agniel, postdoctoral fellow1,
  3. Andrew Beam, research scientist1,
  4. Brian Yorkgitis, assistant professor in surgery3,
  5. Mark Bicket, assistant professor in anesthesia4,
  6. Mark Homer, postdoctoral fellow1,
  7. Kathe P Fox, director5,
  8. Daniel B Knecht, chief of staff5,
  9. Cheryl N McMahill-Walraven, director5,
  10. Nathan Palmer, research scientist1,
  11. Isaac Kohane, department chair1
  1. 1Department of Biomedical Informatics, Harvard Medical School, Countway Library, Boston, MA 02215, USA
  2. 2Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
  3. 3Department of Surgery, University of Florida, Jacksonville, Division of Acute Care Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
  4. 4Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
  5. 5Department of Analytics and Behavior Change, Aetna, Blue Bell, PA, USA
  1. Correspondence to: G A Brat gbrat{at}
  • Accepted 1 December 2017


Objective To quantify the effects of varying opioid prescribing patterns after surgery on dependence, overdose, or abuse in an opioid naive population.

Design Retrospective cohort study.

Setting Surgical claims from a linked medical and pharmacy administrative database of 37 651 619 commercially insured patients between 2008 and 2016.

Participants 1 015 116 opioid naive patients undergoing surgery.

Main outcome measures Use of oral opioids after discharge as defined by refills and total dosage and duration of use. The primary outcome was a composite of misuse identified by a diagnostic code for opioid dependence, abuse, or overdose.

Results 568 612 (56.0%) patients received postoperative opioids, and a code for abuse was identified for 5906 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 the rate of misuse of 44.0% (95% confidence interval 40.8% to 47.2%, P<0.001), and 19.9% increase in hazard (18.5% to 21.4%, P<0.001), respectively.

Conclusions Each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.


  • We thank Aetna for donating the dataset. MB was supported by the National Institute of General Medical Sciences of the National Institutes of Health (award No T32GM075774).

  • Contributors: GAB, DA, and MB designed the study. CNMcM-W, DBK, and KPF contributed data tables. GAB and DA wrote the manuscript. GAB, DA, AB, and NP performed the analysis. MH contributed critical analytical tools for the analysis. CNMcM-W, DBK, KPF, MB, IK, and BY contributed citations and evaluated and edited the manuscript. GAB, DA, NP, and IK are guarantors of the data and analysis.

  • Funding: This study received no funding.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The deidentified data in this study were exempt from review by an institutional review board as confirmed by the Harvard Medical School institutional review board committee.

  • Data sharing: No additional data available.

  • Transparency: The manuscript’s guarantors (GAB, DA, NP, and IK) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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