Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

Evan D. Kharasch, M.D., Ph.D.; J. David Clark, M.D., Ph.D.; Jerome M. Adams, M.D., M.P.H.


Anesthesiology. 2022;136(1):10-30. 

In This Article

Postoperative Pain and Opioids: The Problem of Variability

The seminal and intractable problem is inter- and intrapatient variability in postoperative pain and pain relief. Distinct and widely disparate trajectories of postoperative pain and recovery have been identified.[43,44] Postoperative pain and opioid needs can be influenced by ethnic, racial, physiologic, cultural, and religious factors, as well as by age, sex, comorbidities, fear, anxiety, previous pain history, coping style, drug interactions, genetics, health disparities, health literacy, preoperative opioid use, social support, and setting (inpatient vs. outpatient surgery).[45] Considerable variability in postoperative pain and opioid consumption is a consistent finding. For example, across four common operations (laparoscopic cholecystectomy, hernia repair, hip replacement, knee replacement) and 103 hospitals, postoperative pain was common and highly variable (range, 0 to 9 on a 10-point scale).[46] Among nearly 2,400 patients across 12 surgical procedures, there was 25-fold variability in the interquartile range of opioid pills taken after surgery.[47] After Cesarean section, many patients took no or less than 5 opioid pills, while about 20% took all or nearly all of the approximately 30 pills prescribed at discharge,[48,49] and after thoracic surgery, nearly half took no or less than five opioid pills, while nearly 30% took all or nearly all.[48]

Variability in postoperative pain and opioid use is accompanied by considerable variability in postsurgical opioid prescribing. Indeed, such variability is even greater for surgical than for medical conditions.[45] For example, in adults, after total knee arthroplasty, the interquartile range of postdischarge oral opioids prescribed to opioid-naïve patients was 75 to 475 mg morphine equivalents, and the total range was 0 to 1,500 mg.[50] In children, after the common outpatient operations tonsillectomy and hernia repair, postsurgical opioid prescribing is similarly highly variable.[51] This is reflected in numerous other procedures as well, in both adults[52] and children.[53] Variability is great even among members of the same surgical team, and between provider type. For example, after discharge from five common inpatient surgical procedures, ranges of 6 to 72, 6 to 189, and 5 to 1,000 opioid pills, equivalent to 30 to 600, 30 to 1,600, and 25 to 1,000 morphine milligram equivalents, were prescribed by attending surgeons, residents, and advanced care practitioners, respectively.[54] Variability in postoperative opioid prescribing is also influenced by surgeons' years of practice, credentialing, type of surgery, and geographic location.[55] Variability ranges from micro scale (within the same surgery service in just one hospital),[56] to macro scale (across countries and continents).[57]