The length of time that opioid patients are medicated, rather than their prescribed dosage, increases the risk for opioid misuse, according to a study published in the BMJ.

Gabriel A Brat, MD, of the Department of Biomedical Informatics, at Harvard Medical School and associates, conducted a retrospective group analysis to assess the effects of post-operational prescriptions on abuse in opioid-naïve patients.

Patient information was obtained for 37,651,619 patients; 1,015,116 were opioid naïve and eligible for further investigation. “Opioid naïve” was defined as less than 7 days of total opioid use in the 60 days pre-surgery.  These eligible members of the study were monitored for a median of 2.67 years.

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Following the index surgery, 568,612 patients (56%) were prescribed a postoperative opioid, and 90% of those prescriptions were filled within the first 3 days of hospital leave. In the succeeding follow-up session, 5906 (0.6%) patients of the total cohort misused their prescribed opioid.

Musculoskeletal (n=367,317), digestive (n=293,905), and integumentary (n=106,914) system surgeries were the 3 most common with reported patient opioid misusage in 2448, 1825, and 533 patients, respectively.

The investigators noticed a trend in the number of post-discharge prescriptions and rates of misuse, noting that the rate of overall misuse was low, but quickly increased as opioid use increased. There was a great increase in rates of opioid misuse among patients with one refill (86,654 [15.2%]) as opposed to those with no refills (434,273 [76.2%]).

Cumulatively, each added refill increased the rate of misuse by 70.7% prior to adjustments and increased misuse hazard after covariate adjustment by 44.0%. A mean 34.2% increase in the rate of opioid mistreatment was noted with every added week of opioid use. After a covariate adjustment was made, the hazard of misuse increased by 19.9% and dosage did not greatly affect the misuse of the prescribed opioids.

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“Surgeons and non-surgeons are changing the characteristics of their opioid prescriptions, but rates of misuse continue to increase,” the authors wrote.

“Clinicians are trapped between guidelines that recommend shorter duration and lower dosing of opioid drugs and a subset of patients who request or require opioids beyond the initial prescription. With these seemingly conflicting forces at play, our analysis provides a broad evidentiary framework to inform clinician behavior and promote protocol development.”


  1. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naïve patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018 Jan 17. doi:10.1136/bmj.j5790