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Chakrani Z, Stocchi C, Alasadi H, Zubizarreta N, Stern BZ, Poeran J, Forsh DA. Prolonged Opioid Use and Associated Factors After Open Reduction and Internal Fixation of Tibial Shaft Fractures. Orthopedics 2024:1-9. [PMID: 38864647 DOI: 10.3928/01477447-20240605-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND The aim of this retrospective cohort study was to determine the rate of prolonged opioid use and identify associated risk factors after perioperative opioid exposure for tibial shaft fracture surgery. MATERIALS AND METHODS We used the MarketScan Commercial Claims and Encounters database (IBM) to identify patients 18 to 64 years old who filled a peri-operative opioid prescription after open reduction and internal fixation of a tibial shaft fracture from January 2016 to June 2020. Multivariable logistic regression identified factors (eg, demographics, comorbidities, medications) associated with prolonged opioid use (ie, filling an opioid prescription 91 to 180 days postoperatively); adjusted odds ratios (ORs) and 95% CIs were reported. RESULTS The rate of prolonged opioid use was 10.5% (n=259/2475) in the full cohort and 6.1% (n=119/1958) in an opioid-naive subgroup. In the full cohort, factors significantly associated with increased odds of prolonged use included preoperative opioid use (OR, 4.76; 95% CI, 3.60-6.29; P<.001); perioperative oral morphine equivalents in the 4th (vs 1st) quartile (OR, 2.68; 95% CI, 1.75-4.09; P<.001); age (OR, 1.03; 95% CI, 1.02-1.04; P<.001); and alcohol or substance-related disorder (OR, 1.66; 95% CI, 1.15-2.40; P=.01). Patients in the Northeast and North Central (vs South) regions had decreased odds of prolonged use (OR, 0.61-0.69; P=.02-.04). When removing preoperative use, findings were similar in the opioid-naive subgroup. CONCLUSION Prolonged opioid use is not uncommon in this orthopedic trauma population, with the strongest risk factor being preoperative opioid use. Nevertheless, shared risk factors exist between the opioid-naive and opioid-tolerant subgroups that can guide clinical decision-making. [Orthopedics. 202x;4x(x):xx-xx.].
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Zhang J, Bradshaw F, Duchniewicz M, Fernandes FW, Geetala R, Krkovic M. Factors Affecting Upper Limb Fracture Opioid Requirements. Cureus 2024; 16:e56499. [PMID: 38638745 PMCID: PMC11026122 DOI: 10.7759/cureus.56499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction Understanding the different opioid pain relief requirements between patients with upper limb fractures can be useful in forming specific evidence-based guidelines and balancing patient-clinician prescribing discussions with opioid stewardship. We investigated the predictors for opioid requirements in upper limb fractures. Methods We retrospectively investigated all upper limb fractures from the shoulder to the wrist treated at a major trauma center from January 2015 to January 2022. The data collected consisted of fracture location, demographics, comorbidities, and management options. Post-injury opioid prescriptions in the first post-injury year were calculated every month up to six months and then grouped from the seventh to the 12th month and converted to morphine milligram equivalents (MMEs). We then calculated days requiring at least one medication (representing the "coverage") and relative "strength" in each time period. Results Six thousand four hundred thirteen patients sustaining a combined 9125 fractures were included in the study, with an MME mean of 436. Fracture locations of the scapula, proximal humerus, humeral shaft, distal humerus, and proximal ulna all had significantly higher MME requirements (p<0.05) at the one-year level. The radius shaft and distal radius had significantly lower MME requirements (p<0.05). The patients with depression, diabetes, drug abuse history, obesity, pulmonary circulatory disorder, and rheumatological conditions required higher strength of opioids at the one-year level (p<0.05). The patients with chronic kidney disease, depression, pulmonary circulation disorder, and rheumatological conditions required higher coverage of opioids at the one-year level (p<0.05). Conclusion Our study presents a high-resolution breakdown of the post-injury opioid requirements for patients with upper limb injuries. Fractures of the scapula, proximal humerus, and shaft of the humerus were associated with increases in both opioid strength and coverage. Depression, pulmonary disease, and rheumatological conditions were all associated with increased opioid strength and coverage. This provides a framework for which clinicians and patients can more accurately anticipate the course of the rehabilitation journey and risk stratify appropriately at the outset of injury.
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Affiliation(s)
- James Zhang
- Department of Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | - Florence Bradshaw
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Michal Duchniewicz
- Department of Trauma, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | | | - Rahul Geetala
- Department of Trauma and Orthopedics, University of Cambridge, Cambridge, GBR
| | - Matjia Krkovic
- Department of Trauma and Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
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Xu AL, Humbyrd CJ. Strategies for Reducing Perioperative Opioid Use in Foot and Ankle Surgery: Education, Risk Identification, and Multimodal Analgesia. Orthop Clin North Am 2023; 54:485-494. [PMID: 37718087 DOI: 10.1016/j.ocl.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
There remains a high prevalence and substantial risks of opioid utilization amongst orthopedic patients. The goal of this review is to discuss strategies for responsible opioid use in the perioperative setting following foot and ankle orthopedic surgeries. We will highlight 1) education interventions, 2) risk identification, and 3) non-opioid alternatives for postoperative pain management.
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Affiliation(s)
- Amy L Xu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Casey Jo Humbyrd
- Orthopedic Surgery, University of Pennsylvania, 230 West Washington Square, 5th Floor, Philadelphia, PA 19107, USA.
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Rooney EM, Odum SM, Hamid N, Irwin TA. Opioid-Free Forefoot Surgery vs Traditional Perioperative Opiate Regimen: A Randomized Controlled Trial. Foot Ankle Int 2023; 44:21-31. [PMID: 36537761 DOI: 10.1177/10711007221140834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND In response to the opioid epidemic, the use of multimodal pain management in orthopaedic surgery is increasing. Efforts to decrease opioid prescribing and opioid consumption among foot and ankle surgical patients are needed. The purpose of this study was to compare the efficacy and adverse events between 2 multimodal pain management pathways for forefoot surgical patients: standard opioid-containing (OC) and opioid-free (OF). METHODS This is a single-center noninferior randomized controlled trial of 51 patients undergoing forefoot surgery allocated to one of 2 perioperative pain management treatments: opioid-free, multimodal (OF, n=27 patients), or traditional opioid-containing (OC, n=24 patients). Patient characteristics, creatine markers, pain (numeric rating scale [NRS]), general health (Veterans Rand 12-Item Health Survey [VR-12]), and depression were measured preoperatively. Postoperatively, pain was measured at 24-hour, 2-week, and 6-week time points. Satisfaction with pain control, complications, and general health were measured at 2 and 6 weeks. RESULTS The OF group is statistically noninferior to the OC group and reported lower median pain scores at 24 hours (2 [IQR 0, 3] vs 6 [IQR 3.5, 7]; p<.0001) and 2 weeks (2 [IQR 1, 4] vs 4 [IQR 0, 3]; p=.018]. By 6 weeks, pain levels were similar between groups. More than 85% of all patients reported satisfaction with pain level at 2 weeks, which increased to >90% at 6 weeks. The VR-12 scores were similar between groups across all time points. At 2 weeks, 8 patients in each group reported constipation. By 6 weeks, all but 2 OC patients reported resolution. No other adverse events of postoperative wound complications, readmissions, medication reactions, thrombosis, or persistent pain were documented. CONCLUSION In forefoot surgery, the opioid-free pain management protocol was statistically noninferior to the opioid-containing protocol in reducing postoperative pain. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
| | - Susan M Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Nady Hamid
- OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Todd A Irwin
- OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
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Reiners N, Vang S, Rivard R, Bostrom N, Nguyen MP. Association of Preoperative Opioid Use With Postoperative Opioid Use and Patient-Reported Outcomes in Ankle Fracture Fixation Patients. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221139787. [DOI: 10.1177/24730114221139787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Ankle fracture surgery is a common procedure with many patients receiving opioid medications for postoperative pain control. Whether there are factors associated with higher medication quantities or patient-reported outcomes, however, remains largely unknown. Methods: Patients with isolated, rotational ankle fractures who underwent surgical fixation between January 2018 and March 2020 were retrospectively reviewed. Patient demographics, injury characteristics, and preoperative and postoperative opioid prescription information were recorded. Clinical follow-up and Foot and Ankle Ability Measure (FAAM) questionnaires were collected at 6 weeks and 3 months postoperatively. Multiple linear regression was used to examine the influences of age, sex, body mass index (BMI), fracture characteristics, medical comorbidities, and preoperative opioid use (OU) on postoperative opioid morphine milligram equivalent (MME) amount and FAAM scores. Results: A total of 294 patients were included with an average age of 52.11 ± 17.13 years (range, 18-97). Fracture types were proportional to one another. Chronic pain (mean = 145.89, 95% CI = 36.72, 255.05, P = .0009), preoperative OU (mean = 178.22, 95% CI = 47.46, 308.99, P = .0077), psychiatric diagnoses (mean = 143.81, 95% CI = 58.37, 229.26, P = .001), tobacco use (mean = 137.37, 95% CI = 33.35, 229.26, P = .0098), and trimalleolar fractures (mean = 184.83, 95% CI = 86.82, 282.84, P = .0002) were associated with higher postoperative opioid MME amounts. Older age (mean = ‒0.05, 95% CI = ‒0.08, –0.02, P = .0014) and higher BMI (mean = ‒0.06, 95% CI = ‒0.12, 0.00, P = .048) were both independently associated with lower FAAM scores at 6 weeks. At 3 months, higher BMI (mean = ‒0.09, 95% CI = ‒0.13, –0.04, P = .0002), bimalleolar fractures (mean = ‒1.17, 95% CI = ‒2.17, –0.18, P = .021), and higher postoperative MME amounts (mean = ‒0.10, 95% CI = ‒0.19, –0.01, P = .0256) were each independently associated with lower FAAM scores. Conclusion: In this study, we found that patients with chronic pain, preoperative OU, psychiatric diagnoses, tobacco use, and trimalleolar fractures were more likely to have higher amounts of opioid prescribed following ankle fracture surgery. However, only age, BMI, bimalleolar fractures, and postoperative MME amount were associated with lower FAAM scores postoperatively. Level of Evidence: Level III, retrospective cohort study.
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Affiliation(s)
- Nicholas Reiners
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Sandy Vang
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopedic Surgery, Regions Hospital, St Paul, MN, USA
| | - Rachael Rivard
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas Bostrom
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Mai P. Nguyen
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopedic Surgery, Regions Hospital, St Paul, MN, USA
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