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Background Since the early 1990s, opioids have been used as a mainstay for pain management surrounding fracture injuries. As opioid dependence has become a major public health issue, it is important to understand what factors can leave patients vulnerable. The purpose of this study was to examine what risk factors, patient or injury severity, contribute most to postoperative opioid dependence following surgical treatment of proximal humerus fractures (PHFs). Methods A retrospective review of all patients who underwent an open reduction and internal fixation of PHF was performed within a large multisite hospital system. Recorded variables included age, gender, ASA class, BMI, fracture type, time to surgery, pre- and postoperative opioid prescriptions, physical and psychological comorbidities, smoking status, and complications. Pre- and postoperative opioid dependence was defined as prescription opioid use in the 3 months leading up to or following surgery. Odds ratio calculations were performed for each variable, and a multivariate logistic regression was used to compare all predictors. Results A total of 198 surgically treated PHFs were included in the cohort with an average age of 59.9 years. Thirty-nine cases were determined to be preoperatively opioid dependent while 159 cases were preoperatively opioid naïve. Preoperative opioid dependence was found to be a significant risk factor for postoperative narcotic dependence, carrying a 2.42 times increased risk. (CI 1.07–5.48, p = 0.034). Fracture type was also found to be a risk factor for postoperative dependence, with complex 3- and 4-part fracture patients being 1.93 times more likely to be opioid dependent postoperatively compared to 2 part fractures (CI 1.010–3.764, p = 0.049). All other factors were not found to have any significant influence on postoperative opioid dependence. Conclusions Our results demonstrate that the most important risk factors of postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity. It is important for orthopedic surgeons to ensure that patients who have more complex fractures or are preoperatively opioid dependent receive adequate education on their increased risk and support to wean off of opioids following surgery. Level of evidence III

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