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Background The immediate postoperative period is high-risk for patients with psychiatric comorbidities or substance use disorders, who are prone to prolonged opioid use. Transitional Pain Services (TPSs) support pain control, tapering, and recovery, but predictors of high utilization are unclear.Methods We conducted a retrospective cohort study of surgical patients managed by TPS at a Veterans Affairs medical center from February 2024 to February 2025. Outcomes included total postoperative opioid use (morphine milligram equivalents, MME), TPS duration (days), and provider contacts, analyzed using multivariable linear regression (one-sided winsorization at 90th percentile). Predictors included demographics, pain catastrophizing, psychiatric/substance use history, and preoperative opioid use.Results Among 345 patients, 94% had chronic pain, 26% used opioids preoperatively, 69% had psychiatric diagnosis, and 79% had substance use history. Of preoperative opioid users (n=88), 68% achieved dose reduction; only 3.2% of the full cohort were discharged on higher doses. Median postoperative use was 218 MME (IQR 165–428), TPS duration 31 days (IQR 12–36), provider contacts 5 (IQR 3–6). Pain catastrophizing was the strongest predictor: each point increase was associated with 31 MME higher opioid use (p=0.023), 3.9 additional TPS days (p<0.001), and increased contacts (p=0.015). Active nicotine use (β=109 MME, p=0.005) and preoperative opioid ≥50 MME/day (β=169 MME, p=0.006) also predicted higher opioid consumption.Conclusions Pain catastrophizing and substance use markers predicted higher TPS utilization and opioid use, highlighting the value of preoperative psychosocial screening. Limiting dose escalation to 3.2%, despite increased baseline risks, demonstrates the effectiveness of well-resourced TPS programs.