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Opioid prescription levels and postoperative outcomes in orthopedic surgery

Cozowicz, Crispianaa,b; Olson, Ashleyc; Poeran, Jashvantc; Mörwald, Eva E.a,b; Zubizarreta, Nicolec; Girardi, Federico P.d; Hughes, Alexander P.d; Mazumdar, Madhuc; Memtsoudis, Stavros G.a,b,*

doi: 10.1097/j.pain.0000000000001047
Research Paper
Global Year 2017

Given the basic need for opioids in the perioperative setting, we investigated associations between opioid prescription levels and postoperative outcomes using population-based data of orthopedic surgery patients. We hypothesized that increased opioid amounts would be associated with higher risk for postoperative complications. Data were extracted from the national Premier Perspective database (2006-2013); N = 1,035,578 lower joint arthroplasties and N = 220,953 spine fusions. Multilevel multivariable logistic regression models measured associations between opioid dose prescription and postoperative outcomes, studied by quartile of dispensed opioid dose. Compared to the lowest quartile of opioid dosing, high opioid prescription was associated with significantly increased odds for deep venous thrombosis and postoperative infections by approx. 50%, while odds were increased by 23% for urinary and more than 15% for gastrointestinal and respiratory complications (P < 0.001 respectively). Furthermore, higher opioid prescription was associated with a significant increase in length of stay (LOS) and cost by 12% and 6%, P < 0.001 respectively. Cerebrovascular complications risk was decreased by 25% with higher opioid dose (P = 0.004), while odds for myocardial infarction remained unaltered. In spine cases, opioid prescription was generally higher, with stronger effects observed for increase in LOS and cost as well as gastrointestinal and urinary complications. Other outcomes were less pronounced, possibly because of smaller sample size. Overall, higher opioid prescription was associated with an increase in most postoperative complications with the strongest effect observed in thromboembolic, infectious and gastrointestinal complications, cost, and LOS. Increase in complication risk occurred stepwise, suggesting a dose–response gradient.

A stepwise opioid dose–dependent increase in numerous postoperative complications, cost, and length of stay was observed suggesting a dose–response gradient.

aDepartment of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA

bDepartment of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria

cDepartment of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA

dDepartment of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA

Corresponding author. Address: Department of Anesthesiology, Hospital for Special Surgery, Department of Public Health, Weill Cornell Medical College, 535 East 70th St, New York, NY 10021, USA. Tel.: 212-606-1206; fax: 212-517-4481. E-mail address: (S. G. Memtsoudis).

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received February 15, 2017

Received in revised form July 14, 2017

Accepted August 21, 2017

© 2017 International Association for the Study of Pain
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