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Increased Opioid Prescriptions in Patients with Preoperative DOAC Use Undergoing Soft Tissue Hand Surgery: A Propensity Score Matching Analysis
Thompson Zhuang, MD MBA; Hannah Hoeun Lee, MD, PhD
University of Pennsylvania, Philadelphia, PA
Introduction: Recent advances in perioperative pain management have led to the widespread adoption of opioid-free pain protocols in soft tissue hand surgery. However, these regimens critically involve the use of non-steroidal anti-inflammatory drugs (NSAIDs), which are contraindicated in patients on direct oral anticoagulants (DOACs) - a growing population. We tested the hypothesis that preoperative DOAC use is a predictor of increased perioperative opioid prescriptions in soft tissue hand surgery.
Methods: We identified opioid-naïve adult patients undergoing carpal tunnel/trigger finger/DeQuervain release or hand/wrist mass excision using a national administrative claims database. Patients with preoperative DOAC prescriptions were propensity score matched to those without. The primary outcome was the incidence of perioperative opioid prescriptions. Secondary outcomes assessed included the incidence of new, persistent opioid use as well as hand therapy and emergency department (ED) visits within 90 days after surgery. Multivariable logistic regression models were constructed for each cohort to evaluate the association between perioperative opioid prescription and secondary outcomes, adjusting for age, sex, region, insurance plan, and Elixhauser comorbidity index.
Results: Of 1,339,734 eligible patients undergoing soft tissue hand surgery, 15,899 (1.2%) filled a DOAC prescription within 90 days prior to surgery. After propensity score matching, patients with preoperative DOAC prescriptions were more likely to be prescribed perioperative opioids (odds ratio = 1.48 [95% confidence interval: 1.40-1.57], p<0.001). The most commonly-prescribed opioids were tramadol (328/569, 58%), hydrocodone/acetaminophen (150/569, 26%), and oxycodone/acetaminophen (51/569, 9%). The incidence of new, persistent opioid use regardless of preoperative DOAC use was 27%. While receiving a perioperative opioid prescription was generally associated with an increase in the odds of postoperative hand therapy utilization and all-cause ED visits, the increase in risk was similar regardless of preoperative DOAC use.
Conclusions: Preoperative DOAC use was associated with an increased incidence of perioperative opioid prescriptions in patients undergoing elective soft tissue hand surgery, which could lead to new, persistent opioid use. Further research is needed to develop opioid-free pain regimens for patients on a DOAC undergoing elective soft tissue hand surgery.
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