How does opioid use before elective surgery affect mortality? 5 takeaways

Katherine Santosa, M.D., a plastic surgery resident, has teamed up with Dr. Jennifer Waljee and the Michigan OPEN team to investigate the relationship between opioid prescribing and outcomes after surgery from multiple angles. 

A new paper in JAMA Surgery, by Santosa, Waljee and co-authors, looks back along the surgical treatment chain and examines the link between preoperative opioid use and mortality for elective outpatient surgery.

Here are five takeaways from the work.

The research was the next step in a progression

In earlier work with the Michigan Opioid Prescribing Engagement Network (Michigan Open), Santosa and colleagues found that people older than 65 who were opioid naive were more likely than the 18-64 population to use opioids persistently after surgery

That led to another question: What was the risk of fall and injuries among older patients who were prescribed opioids during surgery? The answer: The patients prescribed more opioids were more likely to fall than the others. 

Santosa wondered what things looked like down the road for surgery patients prescribed opioids and if there were more significant outcomes of opioid prescribing after surgery. 

“What happens with mortality? If people are falling more, this could indicate that they may have more severe outcomes after surgery with higher opioid consumption, so we should examine their mortality.”

To answer the question, Santosa and her colleagues sampled Medicare data for people 65 and older who underwent outpatient surgery between January 1, 2009  and September 30, 2015. They focused on patients who were taking opioids in the year prior to surgery and stratified them into categories of use: high, medium, low or opioid naive, based on fill history and continuity of fills.

Pre-operative opioid use and mortality correlate

When the dataset was analyzed, a clear trend emerged: Higher levels of preoperative opioid use tracked with increased 90-day mortality following outpatient surgery. 

Patients in the high-use group were 1.68 times more likely to die within 90 days after outpatient surgery compared to opioid naïve patients. Medium preoperative opioid users also had higher rates of 90-day mortality: They were 1.3 times more likely to die by that milestone than opioid naïve patients. Patients in the low-use and opioid-naive groups had similar mortality rates. 

These trends held even after adjusting for types of surgery—and all of the surgeries were considered minor: procedures such as carpal tunnel release, varicose vein removal and inguinal hernia repair.

“The fact that there was a higher risk of mortality in these different groups after just minor outpatient surgery was surprising to us. It really does highlight the impact preoperative opioid use can have on adverse outcomes like mortality even after minor, outpatient surgical procedures,” Santosa said.

More questions, more research needed

While 90-day mortality scaled up along with higher preoperative opioid use, it’s not clear why. This study did not examine the cause of mortality, and Santosa has thoughts about what might be driving it.  

“One of the things we didn’t look at in the analysis is the effects of polypharmacy. There is a possibility that these patients are on other medications that have significant interaction effects with opioids that make them more likely to die or have more complications from opioids. The other possibility is that being on opioids before surgery may be a marker of a patient having more severe disease or more comorbidities, increasing their mortality risk. Further investigation is necessary,” Santosa said.

Guidelines and interventions needed

The literature on preoperative opioid exposure isn’t vast, and guidelines for managing post-operative pain tend to focus on opioid-naive patients, according to the paper. 

More research into preoperative opioid use could help inform preoperative screening, potential pre-surgery interventions and even prescribing.

“Older patients are prone to the adverse effects of opioids and we should be really judicious about prescribing these potentially harmful medications,” Santosa said. 

Interventions could include weaning patients off of opioids prior to surgery, delaying discretionary procedures, using adjunct medications, and being mindful of which medications are prescribed alongside opioids, the paper authors state. 

Aging population demands attention

Why is Santosa so focused on an older demographic? It’s a matter of numbers, with the aging population gaining ground. 

According to the U.S. Census Bureau, all baby boomers will be older than 65 by 2030, and older people will outnumber children for the first time in U.S. history.

“We are all going to have to be especially mindful and intentional about treating older surgical patients and knowing that they have different risk factors, require closer postoperative monitoring, and require different prescribing guidelines,” Santosa said. 

The focus on older populations is also personal for Santosa:

“Our research questions have really been focused on older patients undergoing surgery. That’s probably because my parents are older and I’m very cautious about their postoperative care. When they have surgery, I tell them ‘Make sure you don’t take any opioids.‘” 



By Colleen Stone

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