Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients

Abstract

Background: Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice. Methods: We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use. Results: There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001). Conclusion: Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.

Preoperative Opioid Use Results in Greater Postoperative Opioid Consumption After Thumb Basal Joint Arthroplasty

“…20,21 Sacks et al 22 presented a psychological component of opioid consumption, showing that patients undergoing outpatient hand surgery with more catastrophizing pain and decreased mindfulness, attention, or awareness used more opioids after surgery. Wang et al 23 used the PDMP to compare the risks of prolonged opioid use in patients treated surgically versus those treated nonsurgically for common hand pathologies and found prior opioid use to be the only independent risk factor. Wong et al 24 described a preoperative opioid use rate of 23% in their patients who underwent upper extremity procedures.…”

Nonsurgical Providers Provide the Majority of Postoperative Opioid Prescriptions After Hand Surgery

“…Several studies have found that preoperative exposure to controlled substances, including opioids, are predictive of prolonged postoperative opioid use [ 4 , 14 , 15 ]. We found that of the 108 patients who had received an additional opioid prescription postoperatively, 46 (42.6%) had received at least one opioid prescription within six months preoperatively.…”

Evidenced-Based Opioid Prescribing Recommendations Following Hand and Upper-Extremity Surgery

“…After common hand and upper-extremity surgeries, inadvertent postoperative opioid prescribing can lead to dependency, abuse, diversion, death, and poor surgical and nonsurgical treatment outcomes; however, guidelines for appropriate opioid dosing and analgesic strategies are lacking. 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 …”

“…5 , 7 Greater initial prescriptions are associated with higher postoperative opioid usage in hand surgery. 23 , 24 , 25 Opioid use after most soft tissue hand surgeries is <5 opioid tablets, and even 0 when nonopioid analgesics are recommended. 5 , 7 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 Opioid use after bony surgeries is higher than that for soft tissue surgeries.…”

“…Several studies have shown that larger initial prescriptions were associated with a higher postoperative opioid usage in common procedures, including cubital tunnel release, trigger finger release, thumb CMC arthroplasty, and carpal tunnel release. 23 , 24 , 25 Yeung et al 26 showed that hand surgery patients retained unused postoperative opioids in 78% of cases, which may lead to diversion and abuse. Fortunately, there has been a trend toward reducing opioid overprescription by upper-extremity surgeons.…”