OBJECTIVES: Constipation is a frequent side effect of opioids. Data that describe the incidence of opioid-induced constipation (OIC) and its impact on costs, resource use, and outcomes in inpatients are limited. The objective of this study was to investigate costs and resource use associated with OIC in patients undergoing total hip or total knee replacement surgery. METHODS: This retrospective, cohort study used a large hospital administrative database (Premier Healthcare Database) to identify adults discharged after total hip or knee replacement surgery between January 2012 and June 2015 who received an opioid during hospitalization. The OIC cohort was identified using ICD-9 codes and matched 1:1 to patients without OIC using propensity score matching. Adjusted outcomes were estimated using logistic regression analyses for categorical variables, and generalized linear models for continuous variables; p<0.05 was considered significant. RESULTS: Of 788,488 eligible patients, 40,891 (5.2%) had OIC. Post-match OIC and non-OIC patient characteristics were well-balanced. Adjusted analyses showed that compared with patients without OIC, patients with OIC had longer hospital lengths of stay (OIC 3.6 vs. non-OIC 3.3 days, p<0.001), higher costs (OIC $17,479 vs non-OIC $16,265, p<0.001), greater risk of ICU admission (OR = 1.12, p = 0.028), 30-day readmissions (OR = 1.16, p<0.001), and 30-day emergency room visits (OR = 1.38, p = 0.014). Standard laxative use was prevalent in both cohorts (>85%), although use of newer, targeted OIC treatments (lubiprostone, methynaltrexone, naloxegol and alvimopan) was rare (<1%). CONCLUSIONS: Incidence of OIC in patients undergoing total hip or knee replacement receiving opioids was 5.2% and contributed to significantly greater cost and resource utilization compared with non-OIC patents. The potential impact of OIC therapies on bowel function by measuring pre- and post-operative outcomes can be addressed in future studies.