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To explore the clinical and financial implications of preoperative opioid use in major abdominal surgery.Opioids are increasingly used to manage chronic pain, and chronic opioid users are challenging to care for perioperatively. Given the epidemic of opioid-related morbidity and mortality, it is critical to understand how preoperative opioid use impacts surgical outcomes.This was an analysis of nonemergent, abdominopelvic surgeries from 2008 to 2014 from a single center within the Michigan Surgical Quality Collaborative clinical registry database. Preoperative opioid use (binary exposure variable) was retrospectively queried from the home medication list of the preoperative evaluation. Our primary outcome was 90-day total hospital costs. Secondary outcomes included hospital length of stay, 30-day major complication rates, discharge destination, and 30-day hospital readmission rates. Analyses were risk-adjusted for case complexity and patient-specific risk factors such as demographics, insurance, smoking, comorbidities, and concurrent medication use.In all, 2413 patients met the inclusion criteria. Among them, 502 patients (21%) used opioids preoperatively. After covariate adjustment, opioid users (compared with those who were opioid-naïve) had 9.2% higher costs [95% confidence interval (CI) 2.8%–15.6%; adjusted means $26,604 vs $24,263; P = 0.005), 12.4% longer length of stay (95% CI 2.3%–23.5%; adjusted means 5.9 vs 5.2 days; P = 0.015), more complications (odds ratio 1.36; 95% CI 1.04–1.78; adjusted rates 20% vs 16%; P = 0.023), more readmissions (odds ratio 1.57; 95% CI 1.08–2.29; adjusted rates 10% vs 6%; P = 0.018), and no difference in discharge destination (P = 0.11).Opioid use is common before abdominopelvic surgery, and is independently associated with increased postoperative healthcare utilization and morbidity. Preoperative opioids represent a potentially modifiable risk factor and a novel target to improve quality and value of surgical care.