Stanford Study Says Surgery Heightens Opioid Risk

Stanford Study Says Surgery Heightens Opioid Risk

By Ed Coghlan

Does having surgery increase a patient’s risk of becoming chronic users of opioid painkillers?

Stanford University School of Medicine researchers say that a study of health insurance claims showed that patients undergoing 11 of the most common types of surgery were at an increased risk of becoming chronic users of opioid painkillers.

The researchers don’t argue that people should put off surgery.  Instead, they say, it’s a reminder that surgeons and physicians should closely monitor patients’ use of opioids after surgery — even patients with no history of using the pain-relieving drugs — and use alternate methods of pain control whenever possible.

The study was published July 11 in JAMA Internal Medicine.

“For a lot of surgeries there is a higher chance of getting hooked on painkillers,” said the study’s lead author, Eric Sun, MD, PhD, an instructor in anesthesiology at Stanford. Sean Mackey, MD/PhD, professor of anesthesiology, is the senior author of the study.

The researchers examined the risks of chronic opioid use following 11 common types of surgeries. Chronic opioid use was defined in the study as patients who filled 10 or more prescriptions or received more than a 120-day supply of an opioid in the first year following surgery, excluding the first three months after surgery.

Patients who had knee surgery had the largest risk, as they were roughly five times more likely than a control group of nonsurgical patients to end up using opioids chronically, followed by those undergoing gall bladder surgery, whose risk was three-and-a-half times greater than those in the control group.

“We also found an increased risk among women following cesarean section, which was somewhat concerning since it is a very common procedure,” adding that the risk was 28 percent higher than among the control group, Sun said.

Other factors that contributed to an increased risk for chronic opioid use included being male, elderly, taking antidepressants or abusing drugs.

Sun and colleagues set out to examine patients who hadn’t received prescriptions for opioids for at least one year prior to surgery. Among the opioid prescription drugs examined in the study were hydrocodone, oxycodone and fentanyl — the drug responsible for the recent accidental overdose death of legendary musician Prince.

Even when taken exactly as prescribed, opioids carry significant risks and side effects,” said study co-author Beth Darnall, PhD, clinical associate professor of anesthesiology and author of the book Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control over Chronic Pain. “Ideally, opioids are avoided in treating chronic pain, and pain treatment should emphasize comprehensive care, including physical therapy, pain psychology and self-management strategies.”

As a pain psychologist and clinician-scientist, Darnall emphasizes alternate methods of pain management based on evidence-based techniques that can help calm the nervous system such as diaphragmatic breathing, progressive muscle relaxation and mindful meditation.

Subscribe to our blog via email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Authored by: Ed Coghlan

newest oldest
Notify of
Sandy Miller

I wish I could edit my posts, I can’t type very well since my stroke, my hands shake and I hit the wrong keys. So I apologize for all the errors.

Sandy Miller

Drew, I hear you! I had a right Thalamus hemorrhage, and will need pain meds for the rest of my like also I have “Thalamic Pain Syndrome” or Central Pain as it is called now. I am in horrific pain everyday 24/7, burning pain, and other sensations that are too many to list. Every doctor tells me they know that this condition is, but they do NOT! I just had to change primary care doctors and on my first visit to this new doctor he said he is sending me to a pain clinic for my Xanax and my pain med I use for the thalamic pain. He is nuts1 I just had Scoliosis surgery 2 years ago and during the testing before surgery, they found I had a 90% blockage in my right coronary artery, which I had a stent put in before the back surgery could be done. I cannot stand to even wear clothes, the touch and feel of certain materials absolutely kills my skin. I burn all over and stress makes everything terrible and even worse. I told him I had been to physical therapy, pain management and had so many injections before my back surgery, there is no way I want anyone touching me now. He said you are going to get off the Xanax and pain medication. I have panic attacks about 4-5 times a week. They are just something I cannot explain. I told him I am 68 years old and none of my doctors had ever mentioned anything about my Xanax especially! i had to change doctors because my husband’s insurance dropped us and we have to use Medicare, and not having any other type of insurance in our lives chose the supposedly the best Medicare program which they say is “Essence.” You see the only Dr. who ever understood my condition is my neurologist, who is retired and went into semit-retirement because of me, he knows I do not abuse my medication and tells me I need to take it more than what I do. But, I knew this day would come, so I never took the amount prescribed. He is in his 80’s now and has health issues himself. He is just sick about me, he has co-authored books with doctors in Canada for medical students and he gave me a book that is absolutely amazing and shows the brain, surgery and has information on the thalamus. I hope these jerks who are doing this to those of us in such pain by taking our medication away that only just helps us to get thru a day, not forever. When a person has never hurt and been in pain, it is difficult for them to understand, but go after those doctors and junkies not us! It just helps me to get out of bed and be with my grandchildren when they come by to see me. I don’t go around complaining all the time, I try so hard to only… Read more »


My sister has had the misfortune to have been the victim of two unfortunate medical procedures gone wrong. She now lives in constant pain, coupled with the fear that any day they will completely take away the minimal amount of pain medication she is still allowed to have. Her life is a mess and she is not the person she used to be. At least with more pain control she could function. Now she barely leaves her house. This whole situation is shameful. Put the opioid blame where it belongs: on greedy pill mill doctors and street addicts, not legitimate pain patients. Just because you can more easily control those patients doesn’t mean you should.

Carla Cheshire

We identified opioid-naive patients undergoing 1 of 11 common procedures, including several procedures not thought to produce long-term pain (eg, functional endoscopic sinus surgery [FESS]). We then estimated the increased risk for chronic opioid use in the year following surgery by comparing these patients with a reference group of nonsurgical opioid patients. We don’t know why opioids were prescribed to some vs offering surgery. Of course the surgical patients may need opioids over a longer period of time if the surgery was not successful or if there may have been other diseases or problems found.

Main Outcomes and Measures:
Chronic opioid use, defined as having filled 10 or more prescriptions or more than 120 days’ supply of an opioid in the first year after surgery, excluding the first 90 postoperative days. What amount of drugs are in the 10 prescriptions ? For nonsurgical patients, chronic opioid use was defined as having filled 10 or more prescriptions or more than 120 days’ supply following a randomly assigned “surgery date.” Who decides when the “random surgical date is?” That could have a huge bearing on how the statistics are interpreted.

The study included 641 941 opioid-naive surgical patients (169 666 men; mean [SD] age, 44.0 [12.8] years), and 18 011 137 opioid-naive nonsurgical patients (8 849 107 men; mean [SD] age, 42.4 [12.6] years). Why the huge discrepancy in the amount of participants?
Am I reading this right? 641,941 vs 18,011,137 I don’t understand this at all.

Looking at 3 years of data of participants surgical statistics and subsequent opioid prescriptions from CDC data is meaningless when comparing it to non-surgical opioid prescribed participants. It is way too ambiguous!

I do not consider this a viable study.


My doctor has cut me 30 pills a month so I am struggling after taking them for years. I am in process of job searching and cannot even move.
Good story my partner was in hospital had a procedure done on her leg and they never offered her any pain meds as a matter a fact the doctor told her go home take your suboxone that you came in on well they detoxed her with one 10mg oxycodone are you serious when she ask for meds to go home with he said take your suboxone how in same is that leaving people suffering even at hospitals she was in there for five days the last couple day they have her something for pain her legs are showing open skin wounds and flesh with a clasped arch plus the many other problems she has. This has got to stop this is going to be another issue just like the cops are treating Americans like animals and killing them now people had enough and they are fighting back that is what is going to happen here with the pain control. My doctor don’t even call to see if I am ok with the changes he done for three months. What a loser I am so disgusted with this world politicians are doing absolutely nothing for us poor chronic pain patients when is this going to end and they realize it’s not pain patients where the problem is it is street drugs. Where are our constitutional rights as Americans. Massachusetts politicians don’t get it why they hurting the weak once again. I am sick and tired of this bull***t. It’s is driving me crazy. I don’t want disibility I want to work. My partner got off meds two years ago to give her body a break for what to have all these problems and no one cares to help her.

Drew P.

I’ve tried physical therapy and had more surgery than most people. I just want to take charge of my own health. I’m sorry, but when I hear people spout their wisdom about how I should care for myself I wonder where this ignorance and arrogance comes from? Take care of yourself and I’ll do the same. I don’t need more restrictions in my life. I already have enough!

Drew P.

Most of live on SSDI so we don’t have the money to sue and they know that. My God! My divorce/custody case cost me 40k by the time it was done. How much do you think it would cost to sue Dr’s. Who are one of the most “lawyers up”professions there is.

scott michaels

I am lucky, my doctor has not messed with my medications because i am an exemplary patient. With that said, for those of you that have been cut off for no reason, meaning you didnt break the doctor contract, yet was still cut off. You do hace a lawsuit. Its so obvious if you didnt break the contract, tge doctor did. If he cant prove you did wrong, then he or she is in breach. They made you sign, you didnt volunteer. If you experienced problems because if this then call a lawyer. Doctors must honor the. contract as you do. WE MUST START SUING THE CDC, DOCTORS AND INSURANCE COMPANIES IF WE WANT TO BE TREATED. RITH NOW THE SYSTEM IS MOVING ALONG UNCONTESTED. SINCE YOU HAVE BEEN CUT OFF YOU HAVE NOTHING TO LOOSE. THEY (THE COURTS)NEED TO SEE THE PAIN THEY ARE CAUSING AND THE FACT THAT PEOPLE ARE KILLING THEMSELVES OR SEARCHING THE STREETS FOR PAIN RELIEF. MAYBE IF PEOPLE START FIGHTING BACK THE DOCTORS WILL GO BACK TO HELPING THOSE OF YOU IN PAIN. I KNOW I WOULD SUIT IF I WAS IN YOUR PREDICIMENT

connie wagner

I can only repeat that I hope any involved in this stupid and dangerous “fight against opiod abuse” someday find themselves in the type of pain that many of us are being forced back into and can find NOTHING to relieve their pain!! I have been on fairly high dose of opiod pain killers and have had no adverse effects, conversely being forcibly taken off them I have many unwanted and possibly life threatening effects.

Stephen Rodrigues, MD

You cannot use a knife when physical therapy is the corrective choice.
This is mostly misinformed consent. This gives people false hope will drive them into deeper depression and fuel the pain, misery and mental trauma.

Throughout the history of mankind, we have only four choices for the treatment of pain.
1. Medications. The key with taking drugs is that whatever is causing the pain where the pain is located the medicine should eradicate the pain pathology. Without the mother nature does all the mending the patient should be restored back to normal. Just like nothing ever happened. The patient will probably forget they had some rip-roaring infection going on.
2. Surgery - With surgery, the patient should be restored back to normal. Just like nothing ever happened. All the surgical scars will heal, and the patient will probably forget they had appendicitis or whatever.
3. Weight and See - Basically nursing care supportive care while mother nature is doing all the mending.
Those 2/3 options for the only options today’s allopathic providers offer you.

Allopathic’s will not mention the fact that mother nature is doing all the mending. The allopathic want you to believe that you will not get better unless your take pills or you have surgery. Obviously, that’s a lie.

The other lie there perpetuating is it’s all in your head.
Another lie is that just wait for the future will figure out what pain is will find a medication for pain, and we will free you from your pain with a pill.

The 4th has been taken away from use to use #1, and #2 which so not work for muscle pain so can not take the place of #4:

They have decided that the best and most precise treatment for the pain that all of you have doesn’t work.
Well, I’m here to tell you don’t believe them because they have no idea about the pain that is most commonly and primarily located in the muscular system.

This pain can only be treated with #4 which is physical therapy. Specifically hands-on physical therapy.

Not hands-off physical therapy because the mechanism of action of the two physical therapies is different.

Hands-on physical therapy stimulates the muscular tissues and mother nature does all the mending. The mechanism of action of hands-on, dry needling, then needling, how she acupuncture, trigger point injections, Gunn IMS all the same.

These are the ONLY treatments for the pain that are deeply embedded throughout the muscular system.

Joy Shepherd

Perhaps Beth Darnell could walk in my shoes for one day. I have Complex Regional Pain Syndrome in both lower extremities. Due to the fear of addiction and uneven pain relief, my opiod of choice is the Duragesic Patch. Am I dependent on them yes. Do they help my pain, yes. Addicted or hooked, I think not. But to say I could manage my pain with deep breathing and meditation alone , that is just silliness. In certain disease processes, as well as surgeries need to be medicated with opiods. Patients who do not receive addequate pain relief will experience a delay in the healing process.

Drew P.

Brought to you by the same fools who stubbornly hang onto the notion that medical marijuana has no use. I’m just tired of being lied to.


So now because I use low dose opiates to control my pain, this now makes me a chronic opiod user? What a load of CR*P. It seems like every single day some Doctor at some University invents a new term or way to call chronic pain sufferers ADDICTS.
For those of use who have been through step theropies, including physical therapy and other non pharmaceutical theropies like acupuncture and electrostimulation, we know that the pain never goes all the way away. As far as meditation and other forms of mental / psychological exercise. I’ve been involved in martial arts for 40+ years and I can tell everyone that yes meditation will help you deal better with your pain, but nothing will make it go totally away. Not even narcotic medications. The secret is controlling and dealing with your pain, not trying to make it go away. We are the best support group we have but having government sponsored doctors continually putting us down because we need narcotic medications to help control our pain is unforgivable.

Drew P.

Seems to be a lot of them these days. I wonder how all these people they speak of get their pain killers? I have to jump through hoops every month and I’m an actual damaged-thalamus person who will be on pain killers for the rest of my life. My life is hard enough without the nonsence these fools preach.


As noted, a flawed “study”. I like the comment suggesting that lexperiencing chronic pain be a prrequisite to entering the ” pain management” field. Medicine has lots of whiz bang gadgets but they have failed us al in the area of pain relief IMO.


Beth Darnell, PHD. Another irresponsible academic profiting from chronic pain. It’s no coincidence surgery patients require opioids, surgery is needed when the body isn’t functioning properly or is damaged. These researchers leave out the most obvious possibilities from their research such as those in pain seek medical help. Just another fool with a PhD not in medicine for that would be relevant.

This is yet another example of shallow pseudo-science masquerading as fact, published by an name institution (that should know better). While this study could be a springboard for further iterative pain research, in no way should it shape clinical practice or public policy-certainly not to the extent that its authors seem to imply. I suspect that, were a study like this presented in a field where scientific enquiry and high quality epidemiologic research were better established than in pain research, it would never have gotten past peer review for publication. As anyone who has had knee reconstructive surgery can attest, the first 6 months following the surgery-when rehab is critical-can, and often does, hurt like the tortures of the damned! One way to ease the pain is to stop the exercises. But this leads to poor long-term postoperative outcome and worsened functional status. The gall bladder surgery association is more concerning, since this is typically now a laparoscopic procedure, with relatively little post-op pain, and time to full recovery is generally less than 8 wks. Since the study looked at prescription opiate use in months 4 through 12 post-op, implicitly, the researchers had already selected to study a group of outliers-people whose experience is likely not representative of the general population of people having those surgeries in the first place. What is NOT reported in this digest of the study is what percentage of the total patient sample for that surgery these “high-risk” patients represented. Nor is there any mention of any credible drill-down analyses to identify if these patients had legitimate, unequivocal need for ongoing pain relief, beyond the correlative mention of age, gender, depression & substance abuse history (as defined how?). The inference that receiving 120 days or more doses of an opioid over the 8 month period (months 4-12 post-op) constitutes “hooked on opiates” is likewise overly-broad and likely inaccurate. Does taking a single hydrocodone 5/325 tablet, on average, every 4 days constitute “hooked”, in a patient who had a failed, infected knee surgery, requiring 6 months of IV antibiotics, with 2 bone debridement surgeries, then 2 more reconstructive surgeries, then months of painful rehab, constitute “hooked”? Not in my judgment as an addiction med doc. Perhaps if the lead authors had spent more than a few cursory moments talking with real patients on the day of surgery, they might have a more informed perspective, from which they might even generate a valid and meaningful study design. However, that might slow down publications, take time away from pharma studies or billing in 10-minute anesthesia increments, and put tenure tracks for junior faculty at risk. To suggest that a small subset of patients who have had catastrophic or atypical surgical courses just need diaphragmatic breathing, meditation, and/or progressive muscle relaxation is both a disservice to those patients, and a dreadful way to tout Prof. Darnall’s book. Further, if Prof. Darnall believes the evidence basis for the interventions she mentioned is so strong, why weren’t they judged as such… Read more »

scott michaels

It doesnt matter how long a patient needs opioid therapy. If they are on the medication longer then a couple of weeks and it is a dose over a couple of Norcos a day there is a high probability of dependence, Especially if the patient DOES have chronic painThe best way to handle patients that need ling term opioid therapy is as follows. When dispensing, The patient should have a TRUSTED person give out the medication on a daily basis. The patient should not have access. A small device should be made, similar to a time safe that dispenses the medication on a daily basis. The device should be filled with the medication by a pharmacist. This will ensure a patient doesnt take extras if the pain is greater on a given day. If that is the case the doctor should increase the dose if the patient is still experiencig severe pain after being medicated. When a person is hungry they eat, this is also true in regards to pain patients. If the pain is great they will take an extra for the day. This is a major cause of patients going to the doctor early for a refill and loosing trust. When i began opioid therapy almost a decade ago, I knew as everybody should know opioids are addictive period. One though can ve dependent and not addicted in rhe sence that both can not abruptly stop because withdrawls are aweful. Suboxone or any opioid replacement is not a solution for stopping. They best way is extremely slow reduction. The longer you are on the therapy the longer it takes to wean off. For the million or so like myself that have been on high dose therapy for several years, we know these things, nor would we want to stop because our pain is too great without the medication. My wife keeps my medication in a safe i dont know the combination too. She also counts them occassionally to make sure i havent figured out the combo. THIS HAS BEEN VERY VERY SUCCESSFUL FOR ME. i suggest this metgod of dispensing. In worse case scenerios, when a patient needs the medication but also has the addictive gene and does not. have a person in their life to help them,, they should get their medication weekly or even daily from the pharmacist. There are clinics for heroin addicts for a daily dose of methadone, why shouldbt a legitimate chronic pain patient have the same support so they are able to take their medication as directed, stop the spiral before it could ever begin and not become a statistic, This is a solution, for those of you that need medication but fear withdrawls. It would also greatly reduce the number of people that enter the revolving rehab door, reduce the fear doctors and pharmasists have when prescribing and dispencing pain relievers and it will not allow people to use these much needed medications as a form of recreation. Can someone help… Read more »


Where did you find doctors writing 120 days of pain medication. Unheard of. All the conversations about pain medication are always one sided. Can you please try to balance the information. You sound like you can never find anything good about helping people with chronic pain. You should not be so one sided.

Drew P.

Great! Another doctor who does NOT understand neuropathic pain. “Mindful breathing”?! Really!

Why does no one understand that surgery is often the last resort for people with painful injuries and syndromes, and that failures of these surgeries are common and account for much chronic pain?

What I want to know is how many patients in this study were suffering from pain after their surgery?

Studies about opioids might as well be studies on pain, but no researcher factors a patient’s pain into their studies. It’s as though opioids were taken for no reason at all!

To me, it’s no surprise that people regularly have to continue taking opioids after a surgery that left them in pain. Surgery is only done when there was already a problem, and the trauma of surgery is an additional trauma that may not heal properly, leaving a patient with chronic pain the rest of their lives.

I myself was subject to this phenomenon: my surgery was the last resort to fix the increasing pain in my low back and hip. When even that didn’t work, I had no alternative to control my constant pain except opioid pain medication - I’d already tried everything else.

So I’m one of those people that would be counted as continuing on opioids after surgery, even though I take them for the pain the surgery was supposed to “cure” (which is still increasing as I age).

Cathy M

An additional point: On the Stanford blog, it included this paragraph (which also was in the Alternet article (looks like folks just copy the press releases wholesale):

“In addition to regional anesthetics during surgery and pain relief medications such as Tylenol post surgery, these methods can include physical therapy, pain psychology and self-management strategies, the study states. Beth Darnell, PhD, a CO-AUTHOR OF THE STUDY and author of the book: Less Pain, Fewer Pills discussed some of the behavioral treatment methods she also studies. ” (caps mine - I don’t know how to bold here)

Okay –this is NOT an objective scientist! She had written a book stating her strong opinion –then did a study that confirmed that opinion? No one sees a problem here?? This is where disclosure of competing interests (like selling a book!) should be in bold at the beginning of every so-called objective interview. JMO.

Cathy M

I am concerned (once again) about the conflation of co-incidence and CAUSE. They seem to be suggesting that the opioid medication is responsible for the increase in longterm use, rather than (for example) continued pain, complications from surgery, etc. Perhaps the ones who keep taking the medication continue to have pain - and IMO they still can’t prove that this pain is “imaginary”! I know that I had hip surgery that got botched (it dislocated 10 times and had to have surgery again, and even that one was done wrong, according to my new surgeon) and it continues to cause me pain. For Darnell to blithely talk about “pain management” is once again arrogant and naive. I don’t want “control” over my pain - I want pain relief! And if opioids give that to me, then the “significant” side effects (which seem to boil down to needing more and being considered an addict) are preferable to living a half-life (or quarter life) because I’m in constant pain! I am beginning to believe that no one should be allowed to call themselves a “pain expert” until they have had chronic pain of at least intensity 5 for at least 6 months. Until then, they are just playing games with statistics. Also, if these “other methods” are so great, why aren’t we seeing a flood of commenters on this and other pain sites touting how wonderfully effective they are?? Seems to me that for each person who claims to have gotten off opioids and managed with breathing and yoga, there are seven who say they tried everything and only the meds work. (that’s in informal count ;-})

One more thought: Of COURSE surgery could increase the longterm use of opioids - find out if these folks, suffering tremendous pain, finally discovered that there is a medication that relieves pain effectively (that they had never been offered before) and that after the surgery, feeling that pain relief, they decide that living a decent life w/o pain is a vast improvement to hobbling along and taking ibuprofen. Do a survey of these patients and find out if they had other pain, which was controlled by these “new” meds… in which case, the prolonged use makes sense to me.

Mark Ibsen MD

This is tantamount to saying people who buy cars are going to use more tires.
They could just as easily conclude that people who do surgery should learn how to manage pain.
Like I told my brother after his bypass surgery two years ago: having an invasive procedure is like telling your body you’ve been a battle and then left for dead on the battlefield.
Any surgical procedure is a terrible insult not only to your tissues but to your hormonal homeostatic recovery system. People are in pain after surgery!
I hope the Stanford guys win a Nobel Prize for figuring this out

Doc Anonymous

The summary does not describe the severity of overall medical condition of the subjects. And maybe the subjects found that they were actually more functional with the opioids,

Note Prince, by all reports DID NOT use medically prescribe fentanyl. In all likelihood, he succumbe to an overdose of ILLEGALLY produced and ILLEGALLY imported fentanyl. That is an entirely different substance than the fentany that was legally prescribed and legally produced fentanyl. To confuse the two and to equate them simply serves to perpetuate the FAILED DEA WAR ON PAIN PATIENTS. Only the DEA, and NOT pain patients or their doctors, has any ability to control the illicit fentanyl that is killing so many Americans. It is the utter failure of the DEA to control these illicit drugs that is responsible. The blame should rest with the DEA. Equating prescribed fentanyl with illegal fentanyl only perpetuates the misguided War on Pain Patients. That gives the DEA lots of numbers that make them look good on the surface, but it opens the doors wide for the real criminals to continue their production and importation of the deadly illegal chemicals.

As far as pain psychology, it can be a very useful tool, but it cannot replace opioids. Dr. Darnell has a good understanding of the psychology of pain, but when I was in practice, most psychologists in my home town (major metropolitan area) simply refused to take chronic pain patients. There was only one trained pain psychologist in town for most of my career and he too left town.