Author: Megan Rolfzen, MD
The Daily Dose
The opioid crisis has entered a dangerous phase dominated by illicit fentanyl, which is associated with approximately 220 deaths each day in the United States. At the 2026 IARS and SOCCA Annual Meeting, experts discussed whether a patient’s subjective response to opioids may help predict the risk of persistent opioid use, misuse, and opioid use disorder.
Traditional risk assessments rely primarily on demographic, social, and medical factors. The speakers argued that clinicians may also need to evaluate how patients feel after receiving opioids, including whether they experience unusually strong euphoria, improved well-being, or a significant emotional crash afterward.
Persistent opioid use after surgery
Chad Brummett, MD, discussed the role of perioperative prescribing in the development of new persistent opioid use. This is generally defined as opioid use that continues longer than expected for normal recovery after surgery.
Depending on the procedure and patient population, approximately 6% to 19% of patients may develop persistent opioid use following surgery.
The problem varies significantly among countries. Postoperative opioid use is generally higher in the United States and Canada and lower in countries such as Sweden, suggesting that prescribing practices and healthcare culture influence long-term use.
Established risk factors include psychiatric illness, male sex, and residence in socially or economically disadvantaged communities. The amount of opioid consumed during the first 30 days after surgery also appears to correlate with the probability of continued use.
Reducing the size of initial prescriptions and limiting refills can decrease unnecessary exposure. However, prescribing restrictions alone may not identify the smaller group of patients who are biologically or psychologically vulnerable to developing opioid-related problems.
The preaddiction period
Daniel Larach, MD, MS, MA, focused on the “preaddiction” stage, the period between initial opioid exposure and the development of diagnosable opioid use disorder.
Addiction may progress through stages involving intoxication and reward, withdrawal and negative emotional effects, and preoccupation with obtaining or using the drug.
Researchers do not yet have enough longitudinal human data to determine which early opioid responses reliably predict later addiction. However, two experiences may be particularly important:
• The intensity of the initial rewarding or euphoric response
• The severity of the emotional crash or negative feelings that follow
If these subjective responses can be validated as predictors, clinicians may eventually be able to personalize opioid prescribing. A patient who experiences unusually strong euphoria or emotional relief after an opioid might require closer monitoring, a smaller prescription, or greater reliance on nonopioid analgesia.
Emotional state and opioid response
Marie Eikemo, PhD, discussed how a patient’s emotional condition at the time of opioid exposure may influence the drug’s effects and the likelihood of repeated use.
The ongoing Norway Operations and Opioids study is following surgical patients to evaluate how emotional context affects opioid consumption and subjective responses.
Preliminary findings suggest that stress increases self-administration of oxycodone, particularly among men. This indicates that opioids may sometimes be used not only to relieve physical pain but also to reduce emotional distress.
Previous opioid exposure may also change the response. Patients with prior exposure appear more likely to report improved well-being after taking an opioid, while opioid-naïve patients are less likely to experience this effect.
This raises concern that repeated exposure may increase the emotional reward associated with opioids, even when the medication was initially prescribed for legitimate pain.
The euphoria factor
Anesthesiologists commonly evaluate whether an opioid provides adequate analgesia and whether it causes adverse effects such as respiratory depression, sedation, nausea, or itching.
The panel suggested that clinicians should also consider the “euphoria factor.” A patient who reports feeling exceptionally calm, happy, emotionally relieved, or unusually well after receiving an opioid may have a different risk profile from a patient who experiences pain relief without a strong emotional reward.
A favorable subjective response does not mean that a patient will develop addiction. However, it may eventually become one component of a broader assessment that includes psychiatric history, prior substance use, social factors, pain severity, opioid exposure, and postoperative consumption.
Clinical significance
Surgery provides a standardized period during which many previously opioid-naïve patients are exposed to these medications. This creates an opportunity for anesthesiologists and perioperative clinicians to identify patients who may be vulnerable before persistent use develops.
Potential strategies include minimizing unnecessary opioid exposure, using regional anesthesia and multimodal analgesia, monitoring consumption during the first month after surgery, and asking patients about both pain relief and their emotional response to opioids.
Future risk-prediction models may combine medical history, social factors, biologic information, opioid consumption, and subjective drug responses. Such models could support precision prescribing rather than applying the same opioid strategy to every patient.
The central message is that clinicians should assess not only how effectively an opioid relieves pain, but also how the medication makes the patient feel. Recognizing unusually rewarding responses may help identify vulnerability at an earlier and potentially more treatable stage.
Thank you to The Daily Dose and IARS for allowing us to summarize this important discussion of opioid-use risk prediction.