Post-discharge opioid prescribing after surgery in the United States: a population-based analysis of specialty variation and prescribing intensity

Background: The transition from hospital to home after surgery is a vulnerable period, yet post-discharge opioid prescribing varies widely across surgical specialties. This study aimed to characterize these prescribing patterns and evaluate their implications for early postoperative outcomes. Methods: We performed a retrospective cohort study using the 2024 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Adult surgical patients who survived to discharge and had complete discharge analgesic data were included. Opioid prescribing was characterized by daily morphine milligram equivalents (MME), cumulative dose, duration, route, dosing frequency, and renewals. Multivariable regression adjusted for demographics, comorbidities, specialty, operative characteristics, and outcomes. Findings: Among 945,505 surgical patients, 683,828 (72.3%) were discharged with an opioid prescription. Prescribing varied by specialty and procedure, with a mean daily dose of 44.8 MME (Standard deviation, SD 122.1), mean duration of 4.2 days (SD 3.3), and prescription renewals in 28,385 (4.2%) patients. Patients discharged with opioids had shorter hospital stays (2.0 vs 3.3 days; p < 0.001) and lower rates of complications (7.7% vs 11.0%; p < 0.0001), reflecting preferential prescribing among clinically stable patients. Surgical specialty and anesthesia type were the strongest predictors of prescribing intensity, with higher odds of high-intensity prescribing following orthopedic (adjusted Odds Ratio, aOR 6.79, 95% Confidence Interval, CI 6.64-6.93) and neurosurgical procedures (aOR 5.66, CI 5.50-5.83), and spinal anesthesia (aOR 2.27, CI 2.21-2.33; all p < 0.001). Interpretation: Despite national efforts to reduce opioid use, most surgical patients continue to receive opioids at discharge, with specialty-specific variation. Differences in early postoperative outcomes should be interpreted as markers of clinical selection and recovery trajectory rather than evidence of opioid-related benefit. Procedure-specific, recovery-informed prescribing guidelines are needed to minimize avoidable opioid prescribing while ensuring adequate analgesia. Funding: None.