New persistent opioid use following surgery among opioid-naïve patients in the USA: a systematic review and meta-analysis of observational studies
Stephan Frangakis, Scott J Keating, Konrad Pisarczyk, Jan Tuzil, Ann M MenzieBackground
New persistent opioid use (NPOU) after surgery is a serious surgical complication associated with increased risk of opioid abuse, mortality, morbidity, and greater healthcare resource utilization.
Objective
This meta-analysis aimed to estimate the pooled incidence of NPOU following surgery in the USA and examine its association with selected risk factors, patient characteristics, and study characteristics.
Evidence review
PubMed and Embase were searched on March 1, 2024, to identify observational studies published between January 1, 2013, and March 1, 2024, that reported the incidence of NPOU among adult patients newly prescribed opioids for postsurgical pain. Study quality was assessed using the Newcastle-Ottawa Scale for cohort studies. Pooled incidence estimates of NPOU were generated using random-effects models overall and within subgroups stratified by surgery type, payer coverage, exclusion of subsequent analgesia/surgery, and NPOU definitions. Meta-regression analyses were conducted to explore associations between NPOU and select patient attributes. The protocol was registered in PROSPERO (CRD42023446403).
Findings
A total of 43 observational studies (n=6 507 173 participants) were included in the meta-analysis; 8 (18.60%) were rated as low quality, 31 (72.09%) as moderate quality, and 4 (9.30%) as high quality. The pooled incidence of NPOU was estimated to be 7.15% (95% CI 6.02 to 8.38), with high heterogeneity (I 2 =100%) and a 95% prediction interval of 1.34% to 17.02%. Metaregression analyses indicated that the pooled estimate was not significantly associated with study sample size, racial distribution, proportion of male patients, or mean age. Estimates of NPOU did not differ significantly by surgery type (p=0.4912), payer coverage (p=0.0697), or subsequent analgesia/surgery (p=0.6335). However, incidence estimates were significantly higher in the 35 studies defining NPOU as opioid use within 90–180 days after surgery (8.29%, p<0.0001) compared with eight studies applying a more stringent definition of NPOU requiring evidence of opioid use over a 180-day postoperative period (2.89%).
Conclusions
This large meta-analysis indicates that NPOU is a common but highly variable outcome among opioid-naive surgical patients in the USA who are prescribed opioids for acute pain. Given the high volume of surgeries performed annually, these findings suggest millions of patients may be at risk for persistent opioid use and related adverse outcomes. However, results should be interpreted cautiously, given the substantial between-study heterogeneity and the inherent limitations of the observational studies included. These findings highlight an urgent need for effective non-opioid pain management strategies and policies to improve access to safer alternatives.