A new study shows which kinds of patients are most likely to be taking opioid pain medications before they have surgery, and could help guide surgical teams toward safer prescribing for post-surgery pain control and overdose prevention.

Researchers from the University of Michigan (U-M) looked at how often patients scheduled for surgery at U-M hospitals said they were already using opioids, and which surgery types and patient characteristics were linked to a greater chance of such use.

The study (“Prevalence of Preoperative Opioid Use and Characteristics Associated With Opioid Use Among Patients Presenting for Surgery”), published online in JAMA Surgery, finds that nearly a quarter of surgery patients at U-M’s academic medical center were already taking opioid pain medicine before their operations.

Researchers drew on data from more than 34,000 patients in two of U-M’s perioperative research registries: the Michigan Genomics Initiative and the Analgesic Outcomes Study. They examined which demographic and social factors are associated with preoperative opioid use, how the incidence of preoperative opioid use varies by procedure, and how preoperative opioid users compared to opioid-naïve surgical patients.

They found opioid use prior to surgery was very common, with 23% of patients reporting some amount of opioid use. Patients who reported they used tobacco or illicit drugs, and who had higher pain severity, depression, lower life satisfaction, and more medical comorbidities before surgery, were all more likely to be taking opioids before surgery. Those scheduled for spinal or orthopedic surgery had a high incidence of preoperative opioid use, while candidates for thoracic surgery had a low incidence.

“Before we can design an effective intervention to help with the perioperative optimization of patients who present for elective surgery with active opioid use, we need to know who these patients are and what characteristics they may have in common,” said first author Paul Hilliard, MD, assistant professor of Anesthesiology. “This study is the first large-scale effort to better understand these complexities and will inform further research in this area.”

Hilliard and his co-authors note that pre-surgical opioid use and its links to post-surgical problems have been studied in specific kinds of surgery, but no study has looked across a broad range of surgery types and identified the patients most likely to be using the medications before their operation. That kind of understanding, they write, is critical to creating effective strategies for optimization that are tailored to the patient and physician.

“These data show that this is a complicated population, and so simply telling patients to wean or stop using opioids before surgery is not likely effective,” says Hilliard. “We need to develop strategies that acknowledge and directly address the other comorbidities beyond pain that are more common in opioid users, such as depression, anxiety and other substance use and abuse.”

“The associations revealed in this study should, at a minimum, prompt further conversation among surgeons and patients before surgery, regarding preoperative optimization and postoperative pain management,” said study co-author Chad Brummett, MD, professor of Anesthesiology. “Early involvement of primary care physicians and pain specialists, when appropriate, can facilitate the transition of care as well. We hope that through U-M’s Precision Health initiative, we can better understand these patients and create tailored care pathways to attend to their unique needs and decrease postoperative morbidity and mortality.”

Since opioid use has significant implications for pain management, the authors say that surgeons should identify opioid users preoperatively to establish a safe and effective pain management plan. This could include both encouraging lower opioid use before surgery, and careful prescribing of opioids for afterward. Such precision opioid prescribing (finding, for each patient, the right dosage of the right painkiller for the right length of time) could prevent increased opioid dependence and abuse.