New Persistent Opioid Use and Associated Risk Factors Following Treatment of Ankle Fractures

Abstract

Background:The aim of this study was to define the rate of new persistent opioid use and risk factors for persistent opioid use after operative and nonoperative treatment of ankle fractures.Methods:Using a nationwide insurance claims database, Clinformatics DataMart Database, we identified opioid-naïve patients who underwent surgical treatment of unstable ankle fracture patterns between January 2009 and June 2016. Patients who underwent closed treatment of a distal fibula fracture served as a comparative group. We evaluated peritreatment and posttreatment opioid prescription fills. The primary outcome, new persistent opioid use, was defined as opioid prescription fulfillment between 91 and 180 days after the procedure. Logistic regression was used to evaluate the effect of patient factors, and the differences of the effect were tested using Wald statistics. The adjusted persistent use rates were calculated. A total of 13 088 patients underwent treatment of an ankle fracture and filled a peritreatment opioid prescription.Results:When compared with closed treatment of a distal fibula fracture, only 2 surgical treatment subtypes demonstrated significantly increased rates of persistent use compared with the closed treatment group: open treatment of bimalleolar ankle fracture (adjusted odds ratio [aOR], 1.32; 95% CI, 1.10-1.58; P = .002) and open treatment of trimalleolar ankle fracture with fixation of posterior lip (aOR, 1.47; 95% CI, 1.04-2.07; P = .027). Rates were significantly increased (aOR, 1.56; 95% CI, 1.34-1.82; P < .001) among patients who received a total peritreatment opioid dose that was in the top 25th percentile of total oral morphine equivalents. Factors independently associated with new persistent opioid use included mental health disorders, comorbid conditions, tobacco use, and female sex.Conclusion:All ankle fracture treatment groups demonstrated high rates of new persistent opioid use, and persistent use was not directly linked to injury severity. Instead, we identified patient factors that demonstrated increased risk of persistent opioid use. Limiting the peritreatment opioid dose was the largest modifiable risk factor related to new persistent opioid use in this privately insured cohort.Level of Evidence:Level III, retrospective cohort study.

Effect of Opioid Limiting Legislation on Postoperative Opioid Utilization in Patients Treated for Ankle Fractures

“…Many factors, such as preoperative opioid usage and injury severity, can alter the amount of opioids prescribed to a postoperative patient. 1,2,7,8,20 Our study provides evidence that implementation of opioid prescription legislation remains a significant predictor of the number of opioid pills and MMEs per prescription after controlling for variables known to modify prescription patterns. Prior studies on opioid prescription patterns following legislative changes have been performed.…”

“…Additionally, there is some evidence in ankle fractures that injury severity or procedure type may predispose patients to persistent opioid use. 7…”

“…Additionally, there is some evidence in ankle fractures that injury severity or procedure type may predispose patients to persistent opioid use. 7 In light of emerging trends in the literature demonstrating that preoperative opioid use and injury severity portends an increased risk for postoperative opioid use, studies that clearly control for these variables are needed to make more definitive conclusions on the effect of opioid legislation on prescribing patterns. The purpose of this study was to evaluate whether prescription patterns of opioids in the immediate 90-day postoperative period were affected by implementation of legislation after controlling for demographics, injury severity and preoperative opioid usage.…”

Influence of inpatient opioid consumption on persistent use following total knee arthroplasty

“…Our definition of persistent of opioid use begins much sooner after surgery than a 90-day postoperative date designated by similar studies. [10][11][12][13] We defined persistent use after primary TKA as an opioid prescription written by the orthopedic surgeon at the 6-week follow-up visit. For most patients, this represents their third opioid refill and an event that is associated with a significantly increased probability of long-term use.…”

“…Larger amounts of opioid prescribed to patients at the time of hospital discharge have been associated with new, persistent opioid use following many common surgical procedures. [10][11][12][13] These studies suggest that limiting postoperative prescribing can effectively reduce risk among opioid-naïve patients. However, we currently do not know if the amount of opioid consumed by patients recovering in the hospital also plays a role in the development of persistent opioid use.…”