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Prospective Evaluation of Post-Operative Opioid Utilization after Upper Extremity Surgery: We are Over Prescribing!
Asif Ilyas, MD; Jonas Matzon; Jack Abboudi; Christopher Jones; William Kirkpatrick; Charles Leinberry; Frederic Liss, Kevin Lutsky; Mark Wang; Nayoung Kim
Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA

Introduction: While adequate management of post-operative pain with oral analgesics is an important aspect of surgery, it remains unclear how many pills are necessary to appropriately manage post-operative pain. The purpose of our prospective study was two-fold: (1) to evaluate opioid consumption after outpatient upper extremity surgery, and (2) to evaluate opioid utilization patterns in order to develop prescribing guidelines.

Methods: Nine board-certified hand surgery fellowship-trained orthopaedic surgeons prospectively collected data for six consecutive months on all patients undergoing outpatient upper extremity surgery. Data included patient demographics, surgical details, anesthesia type, and opioid prescription and consumption patterns. Linear regression was used for statistical analysis.

Results: A total of 1,466 patients with an average age of 55 years (range 5-93) were included. On average, surgeons prescribed 25 pills (range 0-110), while patients consumed 8.1 pills (range 0-90), resulting in a utilization rate of 32%. Only 6% of patients received disposal information. Soft tissue procedures required less opioids (5.1 pills for 2.2 days) compared to fractures (12.2 pills for 4.1 days) or joint procedures (14.6 pills for 5.0 days) (p<0.01). Both hand and and wrist surgeries utilized an average of 7.6 pills, compared to 10.6 pills for forearm/elbow surgeries, and 22 pills for arm/shoulder surgeries (p<0.01). Patients undergoing surgery with only local anesthesia consumed the least opioids (4.5 pills for 2 days), compared to patients anesthetized with sedation (5.7 pills for 2.6 days), general (12.2 pills for 4.0 days), and regional (15 pills for 4.8 days) (p<0.01). Based on morphine equivalents, procedure type, anatomical location, and anesthesia type significantly influenced the amount of opioid used (p<0.001). In contrast, age and insurance, was found to not statistically affect opioid consumption.

Discussion & Conclusion: To the best of our knowledge this is the largest prospective evaluation of opioid consumption to date and we found that patients in our series are being over-prescribed pain medications post-operatively for hand & upper extremity surgery. Patients only utilized 32% of their prescribed pain medication, thereby leaving 68% of unused prescribed narcotics available for potential diversion. Very few patients (6%) received safe disposal information for excess pain medication by their prescriber, surgical facility, or pharmacy. Surgeons should consider prescribing less pain medications on average and base it upon the procedure type, anatomic location, and mode of anesthesia.

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