Opioid prescribing after surgery in the United States, Canada and Sweden

Importance — Small studies and anecdotal evidence suggest marked differences in the use of opioids after surgery internationally, however this has not been evaluated systematically across populations receiving similar procedures in different countries.

Objective — To determine whether there are differences in the frequency, amount and type of opioids dispensed after surgery between the United States, Canada and Sweden.

Design — Retrospective cohort study of patients undergoing surgery between 2013 and 2016. Analysis was conducted in all three countries in 2018.

Setting — United States, Canada and Sweden.

Participants — Opioid-naive patients aged 18-64 years undergoing four low-risk surgical procedures (laparoscopic cholecystectomy; laparoscopic appendectomy; arthroscopic knee meniscectomy; breast excision) in the US, Canada and Sweden.

Main Outcomes and Measures — The main outcome was postoperative opioid prescriptions filled within 7 days after discharge; we compared the percentage of patients who filled a prescription, the total morphine milligram equivalent (MME) dose and type of opioid dispensed.

Results — The study sample consisted of 129,379 patients in the US; 84,653 in Canada; and 9,802 in Sweden. The proportion of patients in Sweden who filled an opioid prescription within the first seven days after discharge for any study procedure was markedly lower than patients treated in the US and Canada (US, 76.2%; Canada, 78.6%, Sweden 11.1%, P<0.001). For patients who filled a prescription, the mean MMEs dispensed within seven days of discharge was highest in US (247±145), and lowest in Canada (169±93.1). Codeine and tramadol were more commonly dispensed in Canada (57.8%) and Sweden (44.7%) than in the US (6.9%).

Conclusions and Relevance — The US and Canada have a seven-fold higher rate of opioid prescriptions filled in the immediate post-operative period compared with Sweden. Out of the three countries examined, the average dose of opioid for the majority of surgical procedures was highest in the US.