Opioid Prescription After Carpal Tunnel Release Is Declining Independent of State Laws

Daniel J. Cunningham, MD, MHSc; Eliana B. Saltzman, MD; Daniel J. Lorenzana, MD; Christopher S. Klifto, MD; Marc J. Richard, MD; Tyler S. Pidgeon, MD


J Am Acad Orthop Surg. 2021;29(11):486-497. 

In This Article

Abstract and Introduction


Background: The opioid misuse crisis focused attention on opioid overprescribing prompting legislation, limiting prescribing. The purpose of this study was to evaluate of opioid filling surrounding carpal tunnel release (CTR) with the hypothesis that filling has decreased in response to state legislation.

Methods: This is a retrospective, observational study of initial discharge, 30-day, 90-day, and 1-year cumulative opioid filling after CTR in a commercial insurance database between 2010 and 2018. All patients aged 18 and older undergoing CTR and with active insurance status for 6 months preoperative through 30 days, 90 days, and 1 year postoperative were considered for inclusion. Patients undergoing same-day distal radius fracture fixation were excluded. Initial and cumulative perioperative patient, state, and year-level opioid filling rates and volumes in oxycodone 5 mg equivalents (oxycodone 5-mg pills) were evaluated.

Results: Patients filled mean volumes of 33, 72, and 144 oxycodone 5-mg pills in the initial prescription, by 90 days post-op and by 1 year post-op, respectively. First prescription opioid filling volume (35 oxycodone 5-mg pills 2010 and 27 oxycodone 5-mg pills 2018, P < 0.001) and cumulative 90-day filling (96 oxycodone 5-mg pills 2010 and 56 oxycodone 5-mg pills 2018, P < 0.001) have decreased significantly from 2010 to 2018. Ten of 24 (41.7%) of states with opioid-limiting legislation had large (>5 oxycodone 5-mg pills), significant reductions in initial opioid filling volume after legislation. Five of 13 (38.5%) states without opioid-limiting legislation had similar reductions during the study period. Thirteen of 24 (54.2%) states with opioid-limiting legislation had large, notable reductions in 90-day opioid filling volume after legislation. Six of 13 (46.2%) states without opioid-limiting legislation had similar reductions during the study period.

Conclusion: Initial and cumulative opioid filling surrounding CTR has decreased significantly since 2010. However, opioid legislation did not result in substantial changes in rates of large, significant reductions in state-specific opioid prescribing.


Opioid misuse in the United States has gained national recognition as a public health crisis. In 2015, opioids were involved in 33,091 deaths, with almost half of these deaths involving a prescription opioid.[1,2] In addition to institutional and local efforts, federal[3] and state government agencies[4] have instituted various programs to regulate opioid-prescribing practices with the aim of reducing excessive opioid prescriptions. All 50 states have instituted prescription monitoring programs to better track and identify patterns suggestive of problematic opioid prescription or use. Furthermore, individual institutions[5–7] have adopted opioid-limiting policies. A heterogeneous patchwork of state governments–enacted opioid limiting legislation also exists.[4] State legislation has variably targeted opioid prescription duration (ie, days prescribed) and/or volume (oral morphine equivalents prescribed). However, these limitations often do not target specific procedures, so the same restrictions may apply to major, invasive surgery (ie, spine fusion surgery) and minor soft-tissue procedures (ie, carpal tunnel release [CTR] and trigger finger release).

Within orthopaedic surgery, growing recognition of the need to use the fewest opioids in the smallest dose for the shortest time possible after orthopaedic surgical procedures is observed. Orthopaedic surgeons are the third-highest group of opioid prescribers among physicians, accounting for nearly 8% of all opioid prescriptions in the United States.[8,9] Evidence exists that notable overprescribing of opioids after orthopaedic surgical procedures exists.[10–16] For example, Kim et al[15] demonstrated that patients undergoing an upper extremity surgical procedure used only 34% of the opioid medications prescribed. For soft-tissue procedures around the hand and wrist, literature exists suggesting limiting narcotic prescriptions to 0 to 20 commonly prescribed pills.[6,7] Rogers et al reported that patients who underwent soft-tissue procedures about the hand and wrist used on average nine pills,[13] and Chapman et al[12] prospectively reported that opioid consumption after CTR averaged 4.3 pills with 87% of patients consuming 10 or fewer pills and 41% consuming no opioids at all. At the same time, patients in the United States (US) undergoing surgery are prescribed considerably more opioids than patients in other countries. Patients in the United States filled opioid prescriptions at a rate seven times higher than patients in Sweden after similar surgeries.[17] Opioid prescribing should not necessarily be viewed as standard of care after minor soft-tissue surgery.

CTR for carpal tunnel syndrome is one of the most common[18] and successful[19] procedures done by orthopaedic surgeons in the United States. Thus, examining opioid prescribing practices after CTR may help the orthopaedic community understand its response to local, state, and national changes in opioid prescribing legislation and shifting public perceptions of opioids. The purpose of this study was to evaluate the longitudinal impact of opioid-related legislation on perioperative opioid prescribing with the hypothesis that state legislation has resulted in a significant decrease in perioperative opioid prescribing for CTR.