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Doubling Up: Concurrent Perioperative Opioid and Benzodiazepine Utilization in Opioid-Naïve Patients Undergoing Soft Tissue Hand Surgery
Thompson Zhuang, MD MBA; Ellis Berns, MD; Andrew D Sobel, MD
University of Pennsylvania, Philadelphia, PA
Introduction: While concomitant opioid and benzodiazepine use is discouraged due to the increased risk of sedation/overdose, the extent of perioperative opioid utilization in hand surgery patients using benzodiazepines is unknown. We asked: Is there a difference in 1) percentage of patients prescribed opioids or amount of opioids prescribed perioperatively and 2) incidence of new, persistent postoperative opioid utilization, between patients undergoing soft tissue hand surgery with preoperative benzodiazepine use and those without.
Methods: Using an administrative claims database, we identified adults undergoing carpal tunnel, DeQuervain, or trigger finger release, palmar fasciectomies, ganglion/mucoid cyst removals, and hand/wrist soft tissue mass excisions from 2011-2021. Patients with prior opioid, benzodiazepine, or substance dependence disorders, or who filled opioid prescriptions before the perioperative period, were excluded. We identified patients with benzodiazepine prescriptions within 90 days before surgery. Outcomes included the percentage of patients prescribed opioids, amount of opioids prescribed in the perioperative period (31 days before surgery to 14 days after surgery), and percentage of patients with new, persistent opioid utilization (continued opioid prescriptions between 91-180 days after surgery). We used multivariable regression models to adjust for age, sex, region, insurance, procedure, and comorbidities.
Results: Of 1,031,320 eligible patients undergoing soft tissue hand surgery, 65,408 (6.3%) had benzodiazepine use within 90 days before surgery. Patients with benzodiazepine utilization had a higher incidence of perioperative opioid prescriptions (66.4% vs. 44.9%), amount of opioids filled (191.4 vs. 181.1 morphine milligram equivalents [MMEs]), and new, persistent opioid use (15.7% vs. 10.8%) compared to patients without benzodiazepine use (all p<0.001). After accounting for covariates, the odds ratio for filling an opioid prescription was 2.48 (95% confidence interval [CI]: 2.44-2.52) for patients with benzodiazepine use. In the multivariable analysis, patients with benzodiazepine use received +30.5 (95% CI: 28.5-32.5) MMEs and had an odds ratio of 1.48 (95% CI: 1.44-1.52) for developing new, persistent opioid use after soft tissue hand surgery compared to patients without benzodiazepine use.
Conclusions: In patients undergoing soft tissue hand surgery, those using benzodiazepines are prescribed opioids more frequently, at higher amounts, and have a higher incidence of developing new, persistent opioid utilization. Given the risks of simultaneous opioid and benzodiazepine use, surgeons could consider reducing opioid prescriptions in patients who are already using benzodiazepines in favor of nonopioid pain strategies.
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