• John J Riva, Salmi T Noor, Li Wang, Vahid Ashoorion, Farid Foroutan, Behnam Sadeghirad, Rachel Couban, and Jason W Busse.
• McMaster University, Hamilton, Ontario, Canada (J.J.R., F.F.).
• Ann. Intern. Med. 2020 Nov 3; 173 (9): 721-729.

BackgroundOpioids are frequently prescribed for acute musculoskeletal injuries and may result in long-term use and consequent harms.PurposeTo explore factors associated with persistent opioid use after its prescription for acute musculoskeletal injury.Data SourcesSearches of multiple electronic databases, without language restrictions, from inception to 6 January 2020, and reference lists of selected articles.Study SelectionObservational studies of adults with opioid prescriptions for outpatient acute musculoskeletal injuries, in an adjusted model, that explored risk factors for prolonged use.Data Extraction6 reviewers, working in pairs, independently extracted data, rated the quality of studies, and evaluated the certainty of evidence.Data Synthesis14 cohorts with 13 263 393 participants were included. The overall prevalence of prolonged opioid use after musculoskeletal injury for high-risk populations (that is, patients receiving workers' compensation benefits, Veterans Affairs claimants, or patients with high rates of concurrent substance use disorder) was 27% (95% CI, 18% to 37%). The prevalence among low-risk populations was 6% (CI, 4% to 8%; P for interaction < 0.001). Moderate-certainty evidence showed increased odds of persistent opioid use with older age (absolute risk increase [ARI] for every 10-year increase, 1.1% [CI, 0.7% to 1.5%]) and physical comorbidity (ARI, 0.9% [CI, 0.1% to 1.7%]). Low-certainty evidence suggested increased risk for persistent opioid use with past or current substance use disorder (ARI, 10.5% [CI, 4.2% to 19.8%]), prescriptions lasting more than 7 days (median ARI, 4.5%), and higher morphine milligram equivalents per day.LimitationSparse, heterogeneous data with suboptimal adjustment for potential confounders.ConclusionAvoiding prescribing opioids for acute musculoskeletal injuries to patients with past or current substance use disorder, and restricting duration to 7 days or less and using lower doses when they are prescribed, are potentially important targets to reduce rates of persistent opioid use.Primary Funding SourceNational Safety Council. (PROSPERO: CRD42018104968).

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