Opioid Prescribing Practices at Hospital Discharge for Surgical Patients Before and After the Centers for Disease Control and Prevention's 2016 Opioid Prescribing Guideline

Erica Langnas; Andrew Bishara; Rhiannon Croci; Rosa Rodriguez-Monguio; Elizabeth C. Wick; Catherine L. Chen; Zhonghui Guan


BMC Anesthesiol. 2022;22(141) 

In This Article

Abstract and Introduction


Background: The Centers for Disease Control and Prevention's (CDC) March 2016 opioid prescribing guideline did not include prescribing recommendations for surgical pain. Although opioid over-prescription for surgical patients has been well-documented, the potential effects of the CDC guideline on providers' opioid prescribing practices for surgical patients in the United States remains unclear.

Methods: We conducted an interrupted time series analysis (ITSA) of 37,009 opioid-naïve adult patients undergoing inpatient surgery from 2013–2019 at an academic medical center. We assessed quarterly changes in the discharge opioid prescription days' supply, daily and total doses in oral morphine milligram equivalents (OME), and the proportion of patients requiring opioid refills within 30 days of discharge.

Results: The discharge opioid prescription declined by -0.021 (95% CI, -0.045 to 0.003) days per quarter pre-guideline versus -0.201 (95% CI, -0.223 to -0.179) days per quarter post-guideline (p < 0.0001). Likewise, the mean daily and total doses of the discharge opioid prescription declined by -0.387 (95% CI, -0.661 to -0.112) and -7.124 (95% CI, -9.287 to -4.962) OME per quarter pre-guideline versus -2.307 (95% CI, -2.560 to -2.055) and -20.68 (95% CI, -22.66 to -18.69) OME per quarter post-guideline, respectively (p < 0.0001). Opioid refill prescription rates remained unchanged from baseline.

Conclusions: The release of the CDC opioid guideline was associated with a significant reduction in discharge opioid prescriptions without a concomitant increase in the proportion of surgical patients requiring refills within 30 days. The mean prescription for opioid-naïve surgical patients decreased to less than 3 days' supply and less than 50 OME per day by 2019.


Post-surgical prescriptions are a major source of hospital opioid prescriptions at discharge.[1] In the United States, opioids are often over-prescribed to patients after surgical procedures.[2–8] As a result, excess opioids can be a potential source for overdose, misuse, diversion, and new persistent opioid use among surgical patients.[8–14] There is a general consensus among medical providers that postoperative opioid prescriptions should be optimized to balance the provision of effective postoperative pain control and the risk of opioid-related adverse effects.[9–11]

In response to the opioid prescription epidemic, the Centers for Disease Control and Prevention (CDC) of the United States published the Guideline for Prescribing Opioids for Chronic Painin March 2016 to improve the safety and effectiveness of pain treatment and to reduce the risks of opioid use disorder, overdose, and death.[12] The guideline recommended prescribing up to three days' supply for patients with non-surgical acute pain, and suggested a careful assessment of risks and benefits when the prescribed dose exceeds 50 oral morphine milligram equivalents (OME) per day.[12] Significant improvements in opioid prescribing practices in non-surgical patients have been observed after the release of 2016 CDC guideline.[13]

It is important to note that the CDC guideline was not intended to address postoperative opioid prescribing,[12] and the CDC has not yet developed a formal guideline to address opioid prescribing in postoperative patients. Sutherland et al. recently analyzed a private insurance database for patients undergoing 8 common surgical procedures and found an association of decreased opioid dispensing after the CDC guideline in opioid naïve surgical patients, which highlights the potential influence of these guidelines in the surgical setting.[14] However, this study focused on opioids that were filled by patients but did not include data on the opioid prescriptions that were written by providers.[14] Prior studies have found that up to 21% of opioids remain unfilled after surgery.[4] Therefore, it remains unclear if the trends they observed were the result of patients' decision to fill less postsurgical opioid prescriptions, or the result of providers changing their opioid prescribing practices change after the CDC guideline.

To investigate the potential effect of 2016 CDC guideline on provider level opioid prescribing practice, we assessed the opioid prescribing practices for surgical patients upon discharge at a large academic medical center in California between 2013 and 2019 with interrupted time series analysis. We examined trends in the days' supply, total and daily dose of the discharge opioid prescription, and 30-day opioid refill prescriptions written for opioid-naïve patients undergoing all inpatient surgical procedures.