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    Identifying Hand Surgery Patients At Risk for Prolonged Opioid Use

    Dr. Anthony Sapienza reviews the findings of a study of more than 77,000 opioid-naïve adult patients who underwent an elective or trauma-related hand surgery procedure. Which patient factors and which procedures were associated with filling an opioid prescription months after surgery?

    Author

    Anthony Sapienza, MD

    Article

    Johnson SP, Chung KC, Zhong L, et al. Risk of prolonged opioid use among opioid-naïve patients following common hand surgery procedures. J Hand Surg Am. Epub Sept 28, 2016 (in press).

    Summary

    The authors studied insurance claims from the Truven MarketScan databases to identify opioid-naïve adult patients who underwent an elective or trauma-related hand surgery procedure between 2010 and 2012 (N = 77,573 patients).

    All patients had a single Current Procedural Terminology code for an elective or trauma-related hand surgery procedure between January 1, 2010 and December 31, 2012, including:

    • Carpal tunnel release
    • Carpometacarpal (CMC) arthroplasty/arthrodesis
    • Cubital tunnel release
    • Trigger finger release
    • Closed distal radius fracture fixation
    • Flexor tendon repair
    • Metacarpal fracture fixation
    • Phalangeal fracture fixation

    Patients included in the study had no opioid exposure 1 year before surgery, excluding the perioperative period.

    Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. The authors assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression.

    In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days than trauma patients (13.5% vs. 10.5%).

    Younger patients (age 18 to 44 years; 86%) filled a perioperative opioid prescription more frequently than did other age groups. Patients who underwent elective surgery most commonly filled prescriptions for perioperative opioids after CMC arthroplasty/arthrodesis (87%). Patients who had a distal radius fracture fixation were the most likely to fill the perioperative opioid prescription in the trauma-related surgery group (89%).

    Factors associated with prolonged opioid use included:

    • Younger age
    • Female gender
    • Lower income
    • Comprehensive insurance
    • Higher Elixhauser comorbidity index
    • Mental health disorders
    • Tobacco dependence or abuse

    Clinical Relevance

    Opioid analgesics are more commonly prescribed in the United States than in any other country. Deaths from these drugs have increased nearly fourfold from 2001 to 2014, and prescription opioids account for more overdose mortalities than any other drug at approximately 19,000 deaths/year. Surgeons are among the highest prescribers of opioid medication, and the use of opioids for postsurgical pain continues to increase.

    The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures. Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions 90 days after hand surgery.

    Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States. Preoperative counseling and preparedness for procedures known to be at risk for prolonged opiate use (CMC arthroplasty/arthrodesis and closed distal radius fracture fixation) may be critical in adjusting patient’s postoperative pain expectations and willingness to pursue multimodal pain-relieving modalities.

    Author Information

    Anthony Sapienza, MD, is an Assistant Professor of Orthopaedic Surgery, NYU School of Medicine, and Associate Director of Hand Fellowship Program, NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.