Chronic Use of Opioid Medications Before and After Bariatric Surgery

Supplementary Online Content

Raebel MA, Newcomer SR, Reifler LM, et al. Chronic use of opioid medications before and after bariatric surgery. JAMA. doi:10.1001/jama.2013.278344

eFigure. Opioid Dispensings in 60 Days Before and 60 Days After Bariatric Surgery eTable 1. Opioid Classification and Morphine Equivalents Conversion Factors for Opioids Administered by Tablet, Capsule, Liquid, Transdermal Patch, and Transmucosal Formulations eTable 2. ICD-9 Codes for Comorbid Diagnosis of Substance Abuse, Anxiety, Posttraumatic Stress Disorder, and/or Depression eTable 3. ICD-9 Codes for Inclusion and Exclusion of Chronic Pain Diagnoses eTable 4. Therapeutic Classes, Generic Names, and Selected Brand Names of Covariate Medications eTable 5. Types of Opioids Dispensed During the Year Before and the Year After Bariatric Surgery Among Presurgery Chronic Opioid Users eTable 6. Types of Opioids Used Before and After Bariatric Surgery Among 933 Individuals With Chronic Opioid Use Before Bariatric Surgery eTable 7. Unadjusted Characteristics of Chronic Opioid Users According to Whether or Not Both Presurgery and Postsurgery Body Mass Indexes (BMIs) Data Were Available eTable 8. Presurgery and Postsurgery Use of Opioids and Selected Other Analgesic and Adjunctive Pain Medication Classes Among Presurgery Chronic Opioid Users With Presurgery Chronic Pain Diagnoses

This supplementary material has been provided by the authors to give readers additional information about their work.

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eTable 1. Opioid Classification and Morphine Equivalents Conversion Factors for Opioids Administered by Tablet, Capsule, Liquid, Transdermal Patch, and a Transmucosal Formulations

Opioid Conversion Factor Comments per mg Opioid

Short-acting, Schedule II Codeine sulfate 0.15 Hydromorphone 4 Meperidine hydrochloride 0.1 Morphine sulfate 1 Oxycodone (with or without 1.5 acetaminophen, ibuprofen, aspirin) Oxymorphone 3 Fentanyl citrate, transmucosal (lollipop, 0.125 Assumes 50% bioavailability lozenges)

Long-acting, Schedule II Morphine sulfate, sustained release 1 Fentanyl, transdermal 2.4 Assumes one patch delivers the dispensed micrograms/hour over each 24-hour day for three days Methadone 3 Oxycodone hydrochloride, controlled 1.5 release Oxymorphone, sustained release 3 Levorphanol tartrate 11

Non-Schedule II Butalbital and codeine (with or without aspirin, ibuprofen, acetaminophen) 0.15 Codeine+(acetaminophen, ibuprofen, aspirin, or carisoprodol) 0.15 Dihydrocodeine (with or without aspirin, No dihydrocodeine products were ibuprofen, acetaminophen) 0.25 dispensed in this study Hydrocodone+(acetaminophen, ibuprofen, aspirin, or homatropine) 1 Pentazocine (with or without aspirin, ibuprofen, acetaminophen) 0.37 Propoxyphene (with or without acetaminophen, ibuprofen, aspirin) 0.23 No tapentadol products were Tapentadol 2.5 dispensed in this study Tramadol with or without aspirin 0.1

a Adapted from Von Korff M, Saunders K, Ray GT, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24:521–7.

eTable 2. ICD9 Codes for Comorbid Diagnosis of Substance Abuse, Anxiety, Post- Traumatic Stress Disorder, and/or Depression a

ICD9 Code Category Description 291.x Substance abuse Alcohol induced mental disorders 292.x Substance abuse Drug induced mental disorders 303.x Substance abuse Alcohol dependence syndrome 304.x Substance abuse Drug dependence 305.x Substance abuse Nondependent abuse of drugs 300.x Anxiety Anxiety, dissociative, and somatoform disorders 309.81 PTSD Posttraumatic stress disorder 296.2 Depression Major depressive disorder, single episode 296.3 Depression Major depressive disorder, multiple episodes 300.4 Depression Dysthymic disorder 309.0 Depression Adjustment disorder with depressed mood 309.1 Depression Prolonged depressive reaction 309.28 Depression Adjustment disorder with mixed anxiety and depressed mood 311.x Depression Depressive disorder, not elsewhere classified 296.0 Bipolar Bipolar I disorder, single manic episode 296.4 Bipolar Bipolar I disorder, most recent episode (or current) manic 296.5 Bipolar Bipolar I disorder, most recent episode (or current) depressed 296.6 Bipolar Bipolar I disorder, most recent episode (or current) mixed 296.7 Bipolar Bipolar I disorder, most recent episode (or current) unspecified 296.8x Bipolar Other and unspecified bipolar disorders

a Cohort members were considered to have any of these conditions if they had at least one recorded diagnosis code in any setting in the year prior to bariatric surgery.

eTable 3. ICD9 codes for Inclusion and Exclusion of Chronic Pain Diagnoses

ICD9 Codes for Inclusion of Chronic Pain Diagnoses a, b ICD9 Code Category 550.x, 551.x, 552.x, 553.x, 789.0x Abdominal pain/hernia 274, 274.0, 274.00, 274.01, 274.02, 274.03, Arthritis 714, 714.0x, 714.1x, 714.2x, 714.3x, 714.4x, 714.5x, 714.6x, 714.7x, 714.8, 714.89, 714.9x, 715.x, 716.x, 719.3, 731.2 720.x, 721.2, 721.3, 721.41, 721.42, 721.5, 721.6, Back pain 721.7, 721.8, 721.9, 721.90, 721.91, 722.1, 722.10, 722.11, 722.2, 722.30, 722.31, 722.32, 722.39, 722.5, 722.51, 722.52, 722.6, 722.7, 722.70, 722.71, 722.72, 722.73, 722.8, 722.80, 722.82, 722.83, 722.9, 722.90, 722.92, 722.93, 724, 724.0, 724.00, 724.01, 724.02, 724.09, 724.1, 724.2, 724.3, 724.4, 724.5, 724.6, 724.7, 724.70, 724.71, 724.79, 724.8, 724.9, 737.x, 738.4, 738.5, 739.2, 739.3, 739.4, 756.1, 756.11, 756.12, 805, 805.2, 805.4, 805.6, 805.8, 839.2, 839.20, 839.21, 839.42, 846, 846.0, 846.1, 846.2, 846.3, 846.8, 846.9, 847.1, 847.2, 847.3, 847.4, 847.9, 848.5 354, 354.0, 354.00 Carpal tunnel 733.6, 786.52, 848.3, 848.4 Costochronditis and intracostal muscle injury 729, 729.1 Fibromylagia 800.x, 801.x, 802.x, 803.x, 804.x, 805.x, 806.x, 807.x, Fractures and contusions 808.x, 809.x, 810.x, 811.x, 812.x, 813.x, 814.x, 815.x, 816.x, 817.x, 818.x, 819.x, 820.x, 821.x, 822.x, 823.x, 824.x, 825.x, 826.x, 827.x, 828.x, 829.x, 920.x, 921.x, 922.x, 923.x, 924.x 307.89, 338, 338.2, 338.21, 338.22, 338.28, 338.29, General chronic pain 338.4, 739.9, 780.9, 780.96 574.x, 592.x Kidney/gall stones 354.4, 713.5, 718.45, 718.46, 718.47, 718.51, 723.4, Limb extremity pain 724.03, 724.3, 726.12, 726.5, 726.71, 726.72, 726.73, 726.9, 726.90, 726.91, 727, 727.0x, 727.1x, 727.2x, 727.3x, 727.4x, 727.5x, 727.6, 727.60, 727.62, 727.63, 727.64, 727.65, 727.66, 727.67, 727.68, 727.69, 727.7x, 727.8x, 727.9x, 728.71, 729.2, 729.5, 739.6, 739.7, 755.67, 755.9, 831.01, 838.04, 840.9, 842.1, 842.12, 843.8, 843.9, 844.8, 844.9, 845, 845.09, 845.1, 845.13 625, 625.0x, 625.1x, 625.2x, 625.3x, 625.4x, 625.5x, Menstrual pain 625.7x, 625.8x, 625.9x 346.x Migraines 721, 721.0, 721.1, 722, 722.0, 722.4, 722.81, 722.91, Neck pain 723.x, 728.85, 739.1, 805.0, 805.00, 805.01, 805.02, 805.03, 805.04, 805.05, 805.06, 805.07, 805.08, 847, 847.0 353.x, 354.x, 355.x, 356.x, 357.x, 337.0 Neuropathy 715.x Osteoarthritis

ICD9 Code Category 306, 648.73, 710.5, 725, 728.89, 729.4, 733.6, 739.8, Other CMP 786.52, 831.04, 848.3, 848.41, 848.8 711.x, 717.2, 717.3, 717.5, 717.7, 717.83, 717.9, Pain in joint 718.1, 718.31, 718.81, 718.84, 718.87, 719, 719.06, 719.4, 719.40, 719.41, 719.42, 719.43, 719.44, 719.45, 719.46, 719.47, 719.48, 719.49, 726, 726.0, 726.1, 726.10, 726.11, 726.19, 726.2, 726.30, 726.31, 726.32, 726.33, 726.39, 726.4, 726.6, 726.60, 726.61, 726.62, 726.64, 726.65, 726.69, 726.7, 726.70, 726.79, 726.8, 727.61, 831, 835, 836, 836.1, 836.3, 839.69, 839.8, 840, 840.3, 840.4, 840.5, 840.6, 840.7, 840.8, 841.9, 842, 842.01, 842.09, 844.1, 844.2 307.81, 339.1, 339.11, 339.12, 339.22, 784, 784.0, Tension headache 784.00 524.6x, 526.9x, 784.9x, 830.0x, 830.1x TMD/TMJ

ICD9 Malignant Cancer, Dementia, and Psychosis Codes that Precluded Classification of Chronic Pain Diagnoses c 140-208 d Malignant cancer 290.0x, 290.1, 290.10 Dementia and psychosis 290.4x–290.9x 291.2x 294.1, 294.10, 294.11 295.x 297.x 298.x 299.x 300.12–300.15 315.0x, 315.1x, 315.2x, 315.3x, 315.5x 317.x, 318.x, 319.x 331.x 292.82

a The goal of including this list of diagnoses in the definition of chronic pain diagnoses is to maximize the sensitivity of identifying individuals with chronic pain prior to bariatric surgery. Based on work from Von Korff et al,20 Boudreau et al,5 and Campbell et al,41 these diagnoses were all identified as being associated with long term use of opioids at Group Health and KP Northern California over the ten-year period from 1997 - 2006. Inclusion Criteria: Overall, two “groups” of diagnoses were included: (1) Non-specific chronic pain (NCP): General chronic pain and migraines, tension headache, abdominal pain, hernia, kidney/gall stones, menstrual pain, neuropathy, temporomandibular pain (2) Chronic musculoskeletal pain (CMP): back pain, neck pain, fibromyalgia, arthritis, carpal tunnel, limb-extremity pain, pain in joint, "other" CMP, osteoarthritis, fractures and contusions, costochrondritis and intracostal muscle injury To meet the definition of having diagnosed chronic pain pre-bariatric surgery, the individual must have at least two clinic, email, or phone encounters with CMP and/or NCP diagnoses from the list below. There must be at least 90 days elapsed between the first such encounter and the last such encounter in the year prior to surgery. b Any of these diagnoses associated with physical therapy or rehabilitation departments/providers were not included. c Individuals were not classified as having diagnosed chronic pain if they had a diagnosis of malignant cancer or dementia or psychosis in the year prior to bariatric surgery d Except for non-melanoma skin cancer (ICD9 code 173)

eTable 4. Therapeutic Classes, Generic Names, and Selected Brand Names of Covariate Medications

Antidepressants AMITRIP HCL/CHLORDIAZEPOXIDE AMITRIPTYLINE, AMITRIPTYLINE HCL AMOXAPINE BUPROPION, BUPROPION HCL, BUPROPION HYDROBROMIDE, WELLBUTRIN SR CITALOPRAM, CITALOPRAM HBR CLOMIPRAMINE, CLOMIPRAMINE HCL DESIPRAMINE, DESIPRAMINE HCL DESVENLAFAXINE SUCCINATE DOXEPIN, DOXEPIN HCL DULOXETINE, DULOXETINE HCL, CYMBALTA ESCITALOPRAM, ESCITALOPRAM OXALATE FLUOXETINE, FLUOXETINE HCL FLUVOXAMINE, FLUVOXAMINE MALEATE IMIPRAMINE, IMIPRAMINE HCL MAPROTILINE MILNACIPRAN, MILNACIPRAN HCL MIRTAZAPINE NEFAZODONE, NEFAZODONE HCL NORTRIPTYLINE, NORTRIPTYLINE HCL OLANZAPINE/FLUOXETINE HCL PAROXETINE, PAROXETINE HCL PERPHENAZINE/AMITRIPTYLINE HCL PHENELZINE SULFATE PROTRIPTYLINE, PROTRIPTYLINE HCL SELEGILINE SERTRALINE, SERTRALINE HCL, ZOLOFT TRANYLCYPROMINE, TRANYLCYPROMINE SULFATE TRAZODONE, TRAZODONE HCL TRIMIPRAMINE MALEATE VENLAFAXINE, VENLAFAXINE HCL, EFFEXOR XR

Antiepileptics ATROPINE/HYOSCYAMINE/PHENOBARBITAL/SCOPOLAMINE BELLADONNA ALKALOIDS/PHENOBARBITAL CARBAMAZEPINE, CARBAMAZEPINE COMPOUND CLONAZEPAM, CLONAZEPAM ORAL SUSPENSION CLONIDINE-GABAPENTIN-KETAMINE DIVALPROEX SODIUM, VALPROATE, VALPROATE SODIUM, VALPROIC ACID

Antiepileptics (continued) ERGOTAMINE/BELLADONNA/PHENOBARB ETHOSUXIMIDE FELBAMATE GABAPENTIN GABAPENTIN-KETOPROFEN-LIDOCAINE LACOSAMIDE LAMOTRIGINE LEVETIRACETAM OXCARBAZEPINE PHENAZOPYRIDINE-BUTABARBITAL-HYOSCYAMINE PHENOBARB/HYOSC SUL/ATROP SULF/SCOP PHENOBARB/HYOSCY/ATROPINE/SCOP PHENOBARBITAL, PHENOBARBITAL COMPOUND PHENYTOIN, PHENYTOIN SODIUM EXTENDED PREGABALIN PRIMIDONE TIAGABINE HCL TOPIRAMATE ZONISAMIDE

Anxiolytics and Sedative Hypnotics ACETAMINOPHEN/DICHLORALPHENAZONE/ISOMETHEPTENE ALPRAZOLAM AMITRIP HCL/CHLORDIAZEPOXIDE ATROPINE/HYOSCYAMINE/PHENOBARBITAL/SCOPOLAMINE BELLADONNA ALKALOIDS/PHENOBARBITAL BUSPIRONE, BUSPIRONE HCL CHLORAL HYDRATE CHLORDIAZEPOXIDE, CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE/CLIDINIUM, CHLORDIAZEPOXIDE/CLIDINIUM BR, CLIDINIUM & CHLORDIAZEPOXIDE CLORAZEPATE, CLORAZEPATE DIPOTASSIUM DEXMEDETOMIDINE-STUDY DRUG DIAZEPAM ERGOTAMINE/BELLADONNA/PHENOBARB ESTAZOLAM ESZOPICLONE FLURAZEPAM, FLURAZEPAM HCL HYDROXYZINE, HYDROXYZINE HCL, HYDROXYZINE PAMOATE LORAZEPAM LORTAB/ADVIL/PROZAC/CHERRY SYR PAINCT

Anxiolytics and Sedative Hypnotics (continued) MEPROBAMATE MIDAZOLAM OXAZEPAM PHENAZOPYRIDINE-BUTABARBITAL-HYOSCYAMINE PHENOBARB/HYOSC SUL/ATROP SULF/SCOP, PHENOBARB/HYOSCY/ATROPINE/SCOP PHENOBARBITAL, PHENOBARBITAL COMPOUND RAMELTEON SECOBARBITAL TEMAZEPAM TRIAZOLAM ZALEPLON ZOLPIDEM, ZOLPIDEM TARTRATE

Corticosteroids, oral BETAMETHASONE BUDESONIDE DEXAMETHASONE HYDROCORTISONE METHYLPREDNISOLONE PREDNISOLONE, PREDNISOLONE SOD PHOSPHATE PREDNISONE

Muscle relaxants CARISOPRODOL CARISOPRODOL/ASPIRIN CHLORZOXAZONE CODEINE PHOS/CARISOPRODOL/ASA CYCLOBENZAPRINE, CYCLOBENZAPRINE HCL METAXALONE METHOCARBAMOL ORPHENADRINE, ORPHENADRINE CITRATE ORPHENADRINE W/ ASPIRIN & CAFF, ORPHENADRINE/ASPIRIN/CAFFEINE TIZANIDINE, TIZANIDINE HCL

Non-narcotic analgesics ACETAMINOPHEN ACETAMINOPHEN-ISOMETHEPTE ACETAMINOPHEN-ISOMETHEPTENE-CAFFEINE ACETAMINOPHEN-ISOMETHEPTENE-DICHLORALPHENAZONE, ACETAMINOPHEN/ISOMETHEPTENE/DICHLPH, ACETAMINOPHEN/DICHLORALPHENAZONE/ISOMETHEPTENE ACETAMINOPHEN/BUTALBITAL

Non-narcotic analgesics (continued) ACETAMINOPHEN/BUTALBITAL/CAFFEINE ASPIRIN, ASPIRIN EC ASPIRIN-ACETAMINOPHEN-CAFFEINE ASPIRIN/BUTALBITAL/CAFFEINE, BUTALBITAL/ASPIRIN/CAFFEINE ATROPINE/BENZOATE/HYOSCYAMINE/METHENAMINE/METHYLENE BLUE/PHENYL SALICYLATE BUTALBITAL-ACETAMINOPHEN, BUTALBITAL/ACETAMINOPHEN BUTALBITAL-ACETAMINOPHEN-CAFFEINE CARISOPRODOL/ASPIRIN CELECOXIB CHOLINE SALICYLATE/MAGNESIUM SALICYLATE DICLOFENAC EPOLAMINE, DICLOFENAC POTASSIUM, DICLOFENAC SODIUM DICLOFENAC SODIUM/MISOPROSTOL, DICLOFENAC W/ MISOPROSTOL DIFLUNISAL ETODOLAC FLURBIPROFEN, FLURBIPROFEN SODIUM GABAPENTIN-KETOPROFEN-LIDOCAINE HYDROQUINONE,SALICY ACID IN TRIAMCIN OIN HYOSCYAMINE/METHENAMINE/METHYLENE BLUE/PHENYL SALICYLATE/SODIUM PHOSPHATE, MONOBASIC IBUPROFEN IBUPROFEN/PSEUDOEPHEDRINE INDOMETHACIN, INDOMETHACIN COMPOUND KETOPROFEN KETOROLAC TROMETHAMINE LANSOPRAZOLE-NAPROXEN MECLOFENAMATE SODIUM MEFENAMIC ACID MELOXICAM NABUMETONE NAPROXEN, NAPROXEN SODIUM ORPHENADRINE/ASPIRIN/CAFFEINE OXAPROZIN PIROXICAM SALSALATE SULINDAC SUMATRIPTAN SUCC/NAPROXEN SOD TOLMETIN SODIUM TROLAMINE SALICYLATE TROLAMINE SALICYLATE/ALOE VERA

eTable 5. Types of Opioids Dispensed during the Year before and the Year after Bariatric Surgery among Pre-surgery Chronic Opioid Users

Type a Before Surgery After Surgery Direction Morphine % of % of of Equivalents Dispensings Dispensings Change Conversion Factor Hydrocodone combinations 50.5 47.6 Decrease 1 Oxycodone 18.1 19.0 Increase 1.5 Morphine sulfate - LA 5.4 5.5 Increase 1 Propoxyphene 5.4 3.0 Decrease 0.23 Tramadol 4.2 3.8 Decrease 0.1 Codeine combinations 4.0 3.3 Decrease 0.15 Oxycodone CR 3.4 3.8 Increase 1.5 Fentanyl transdermal 2.9 4.4 Increase 2.4 Methadone 2.5 3.5 Increase 3 Hydromorphone 1.7 3.7 Increase 4 Morphine sulfate 1.3 1.8 Increase 1 Oxymorphone-LA 0.2 0.2 Decrease 3 Tramadol-LA 0.2 0.1 Decrease 0.1 Butalbital & codeine 0.1 0.2 Increase 0.15 Codeine sulfate < 0.1 < 0.1 Decrease 0.15 Pentazocine < 0.1 < 0.1 Decrease 0.37 Meperidine < 0.1 < 0.1 Increase 0.1 Levorphanol tartrate < 0.1 None Decrease 11 Oxymorphone None < 0.1 Increase 3

a Transmucosal fentanyl was not dispensed

eTable 6. Types of Opioid Used before and after Bariatric Surgery among 933 Individuals with Chronic Opioid Use before Bariatric Surgery

Time Period Relative to Type of Opioid Bariatric Surgery a Non-Schedule II b Short-acting Schedule II c Long-acting Schedule II d % of % of total % with % of total % with Use % of total Patients Morphine Use Morphine Morphine with Equivalents Equivalents Equivalents Use e (95% CI) (95% CI) (95% CI) One Year Before 85.1 35.5 (35.4-35.5) 41.4 15.4 (15.4-15.5) 27.0 49.1 (49.1-49.1) First Year After 80.1 27.4 (27.4-27.4) 43.3 21.1 (21.0-21.1) 29.1 51.3 (51.5-51.5) Second Year After 74.8 24.4 (24.3-24.4) 43.2 22.5 (22.5-22.5) 29.7 53.1 (53.1-53.1)

a One year before is defined as days -335 through -1 prior to surgery; first year after is defined as days 30 through 364 after surgery, and second year after is defined as days 365 through 729 after surgery b Non-Schedule II = propoxyphene (with or without acetaminophen, ibuprofen, aspirin), codeine plus acetaminophen, ibuprofen, aspirin, or carisoprodol; butalbital and codeine (with or without aspirin, ibuprofen, acetaminophen); hydrocodone (with or without acetaminophen, ibuprofen, aspirin or homatropine); tramadol (with or without aspirin); and pentazocine (with or without aspirin, ibuprofen, or acetaminophen). c Short acting Schedule II = morphine sulfate; codeine sulfate; hydromorphone; meperidine; fentanyl transmucosal; oxymorphone; oxycodone. d Long acting Schedule II = morphine sulfate sustained release (SR); fentanyl, transdermal; levorphanol; oxycodone controlled release (CR); methadone; oxymorphone sustained release. e Percentage of Individuals with Use: percent of chronic opioid users possessing the opioid of interest (i.e., non-Schedule II, SA Schedule II or LA Schedule II) for at least one day during the time period of interest (i.e., one year before, first year after, second year after). Proportions across the three opioid types sum greater than 100% because individuals could possess more than one type of opioid during the same time period of interest.

© 2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 eTable 7. Unadjusted Characteristics of Chronic Opioid Users according to whether or not both Pre- and Post- Surgery Body Mass Index (BMI) Data were Available

Characteristic BMI Data Not All Individuals BMI Data Available a Available P-Value (n = 933) (n = 647) (n = 286) Sociodemographics Age at surgery, median (5th, 95th percentile) 51 (33, 65) 51 (33, 65) 50 (32, 65) 0.07 Gender, % Female 737 (79) 512 (79) 225 (79) 0.87 Race and Ethnicity (%) <0.001 Black 60 (6) 44 (7) 16 (6) White 660 (71) 493 (76) 167 (58) Hispanic, any race 78 (8) 55 (9) 23 (8) Other race 25 (3) 23 (4) 2 (1) Not available 110 (12) 32 (5) 78 (27) Tobacco Use <0.001 Ever Use 339 (36) 300 (46) 39 (14) Never Use 261 (28) 255 (39) 6 (2) Not Available 333 (36) 92 (14) 241 (84) % with less than high school education, median (5th, 95th percentile) b 14 (3, 41) 15 (3, 41) 13 (3, 36) 0.029 Insurance (%) 0.10 Medicare 81 (9) 66 (10) 15 (5) Medicaid 7 (<1) 5 (<1) 2 (<1) Commercial 723 (78) 487 (75) 236 (83) Multiple or other types 108 (12) 79 (12) 29 (10) Not available 14 (2) 10 (2) 4 (1) Clinical Characteristics Number of comorbidities pre-surgery year, median (5th, 95th percentile) 4 (1, 8) 4 (1, 8) 4 (2, 9) 0.018 c Selected diagnoses pre-surgery year (%) Chronic pain d 666 (71) 477 (74) 189 (66) 0.017

Characteristic BMI Data Not All Individuals BMI Data Available a Available P-Value (n = 933) (n = 647) (n = 286) Substance abuse e 159 (17) 95 (15) 64 (22) 0.004 Anxiety e 217 (23) 136 (21) 81 (28) 0.015 PTSD e 22 (2) 4 (1) 18 (3) 0.20 Depression e 301 (32) 188 (29) 113 (40) 0.002 Bipolar disorder e 35 (4) 28 (4) 7 (2) 0.16 Outpatient visits pre-surgery year, median (5th, 95th percentile) 16 (5, 48) 16 (5, 48) 19 (5, 47) 0.01 Type of Surgery 0.09 Gastric sleeve 30 (3) 19 (3) 11 (4) Laparoscopic (Lap) Band 114 (12) 84 (13) 30 (11) Lap Roux-en-Y gastric bypass (RYGB) 564 (61) 402 (62) 162 (57) Open RYGB 148 (16) 96 (15) 52 (18) Other or more than one type 77 (8) 46 (7) 31 (11) First bariatric surgery re-intervention after initial bariatric procedure (%) f 168 (18) 107 (17) 61 (21) 0.08 First inpatient surgery (not bariatric) after initial bariatric procedure (%) f 68 (7) 43 (7) 25 (9) 0.26 Incident chronic pain diagnosis the post-surgery year (%) d 111 (12) 73 (11) 38 (13) 0.38 a Chi-square tests for categorical variables and Kruskal-Wallis tests for continuous variables b % of community members > 25 years of age with <= 12 years education; measured from Census 2000 data c Quan comorbidity index; lower scores represent lower comorbidity burden d At least two coded diagnoses at least 90 days apart e At least one coded diagnosis during the year prior to surgery f 15 to 364 days after initial bariatric procedure

eTable 8. Pre- and Post-surgery Use of Opioids and Selected Other Analgesic and Adjunctive Pain Medication Classes among Pre-surgery Chronic Opioid Users with Pre-surgery Chronic Pain Diagnoses

a b c Fibromyalgia Back pain Osteoarthritis Back pain and Other chronic (n = 104) (n = 193) (n = 119) osteoarthritis d pain types e (n = 151) (n = 99) Pre- Post- Pre- Post- Pre- Post- Pre- Post- Pre- Post- surgery surgery surgery surgery surgery surgery surgery surgery surgery surgery Opioid Use Total Morphine Equivalents Dispensed mean 17,590 21,228 16,211 18,358 16,719 19,069 15,658 17,450 12,927 15,200 (SD) (24,310) (29,900) (24,648) (25,785) (36,205) (46,446) (25,841) (31,093) (18,600) (21,655)

median 7665 9667 8652 9510 6000 6550 7812 6735 6435 8135 (25th, 75th percentile) (3613, (3103, (4265, (3720, (2975, (3000, (4275, (3025, (3540, (3150, 17,342) 24,048) 17,417) 20,663) 13,635) 15,010) 13,350) 17,037) 14,284) 17,880) Use of selected other analgesic and adjunctive pain medication classes, n (%) Antidepressant 83 (80) 83 (80) 142 (74) 134 (69) 69 (58) 61 (51) f 100 (66) 91 (60) f 58 (59) 58 (59) Antiepileptic 36 (35) 36 (35) 59 (31) 61 (32) 22 (19) 17 (14) 45 (30) 38 (25) 26 (26) 24 (24) Antianxiety 43 (41) 52 (50) f 87 (45) 86 (45) 39 (33) 41 (35) 42 (28) 52 (34) 34 (34) 40 (40) Oral corticosteroid 13 (13) 10 (10) 25 (13) 14 (7) f 12 (10) 11 (9) 17 (11) 19 (13) 7 (7) 7 (7) Muscle relaxant 52 (50) 42 (40) f 91 (47) 67 (35) g 22 (19) 18 (15) 55 (36) 36 (24) g 20 (20) 22 (22) Non-narcotic analgesic 95 (91) 85 (82) g 174 (90) 167 (87) 109 (92) 105 (88) 149 (99) 136 (90) h 91 (92) 91 (92)

a With or without a pre-surgery diagnosis of osteoarthritis or back pain; n = 76 (73%) also had at least one pre-surgery non-specific chronic pain diagnosis b No pre-surgery osteoarthritis or fibromyalgia diagnosis; n = 127 (66%) also had at least one pre-surgery non-specific chronic pain diagnosis c No pre-surgery back pain or fibromyalgia diagnosis; 61 (51%) also had at least one pre-surgery non-specific chronic pain diagnosis d No pre-surgery fibromyalgia diagnosis; 96 (64%) also had at least one pre-surgery non-specific chronic pain diagnosis e No pre-surgery back pain, osteoarthritis, or fibromyalgia diagnosis; 74 (75%) also had at least one pre-surgery non-specific chronic pain diagnosis f 0.01 < p < 0.05 pre- to post-surgery pair difference; McNemar’s test g 0.001 < p < 0.01 pre- to post-surgery pair difference; McNemar’s test h p < 0.001 pre- to post-surgery pair difference; McNemar’s test