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

Disclosures

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

In This Article

Discussion

This study reports opioid volume filled, rates of opioid filling, and refills after primary CTR in a large, commercially available database from 2010 to 2018. The purpose of the study was to evaluate the impact of opioid-related legislation on perioperative opioid prescribing with the hypothesis that state legislation would result in significant reductions in opioid prescribing surrounding CTR.

Cumulative 90-day opioid prescription volume has decreased significantly since 2010 (96 oxycodone 5-mg pills in 2010 to 56 oxycodone 5-mg pills in 2018, P < 0.001), which represents a 41.7% reduction in overall prescription filling volume. During the 2011 to 2017 time frame, rates of refill were increased over the baseline 2010 value (23% in 2010 to a maximum of 30% in 2013). The finding of increased refill rates in this time period is intuitive because initial prescription volumes were decreasing over the same time frame. As of 2018, rates of refill have also reached an all-time low (20.1%), possibly reflecting an overall improved balance of achieving adequate postoperative analgesia between prescriber and patient expectations after a CTR. Over this same time frame, first prescription volume has also decreased significantly (34 oxycodone 5-mg pills in 2010 to 27 oxycodone 5-mg pills in 2018, P < 0.001). This represents a 20.6% decrease in first prescription volume for this procedure from 2010 to 2018.

In addition to describing broad changes in national prescription filling patterns over time, this study also evaluated state-specific changes in opioid prescribing after legislation implementation. We found similar rates of large, significant reductions in initial and cumulative opioid prescription filling volumes between states with and without opioid-limiting legislation. At the same time, the magnitude of overall 90-day cumulative decrease was 7 pills greater in states with legislation compared with states without legislation, although initial prescribing was minimally different. Taken together, these findings may indicate that nation-wide awareness and response to the opioid crisis have had a greater impact than state-specific legislation on opioid prescribing. However, this is not to say that state-specific legislation has not been important. Rather, state-specific legislation has likely been an important part of the increase in nation-wide awareness, although its effect is difficult to see in this particular study.

Our findings are in keeping with the overall decline in the national opioid prescribing rate from 2012 to 2017 to the lowest rate in the past 10 years at 58.7 prescriptions per 100 persons.[24] Although our study cannot thoroughly assess the effects of specific legislation or policies, given the considerable heterogeneity in state-led interventions, previous literature has suggested that opioid-limiting regulations have been effective in changing prescribing patterns. For example, Reid et al[25] examined the impact of opioid-limiting laws on postoperative opioid prescribing and secondary outcomes after anterior cervical diskectomy and fusion by comparing a cohort of patients pre-law (December 1, 2015, to June 30, 2016) and post-law (June 1, 2017, to December 31, 2017). Total morphine milliequivalents filled was compared at 30-day postoperative intervals as were 30- and 90-day ED visits, readmissions, and revision surgery rates. The authors concluded that the implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization after anterior cervical discectomy and fusion without a rebound increase in prescription refills, emergency department visits, unplanned hospital readmissions, or reoperations for pain.

From a patient satisfaction perspective, recent studies have demonstrated that opioids result in worse pain control subject and satisfaction compared with over-the-counter medications.[7] One variable possibly contributing to continued overprescription of opioids for postoperative pain management is physicians' concerns regarding patient satisfaction in a climate of widespread use of online patient satisfaction and physician rankings. In a prospective study by Benavent et al[26] of 100 patients undergoing common hand procedures that included CTR, the authors investigated both patient satisfaction with pain management using an opioid-prescribing protocol and medication use in the postoperative period. The authors concluded that patients consumed far fewer opioid pills than were prescribed, with an average number of 1.5 oxycodone pills consumed (11.25 morphine milligram equivalents; 2.02 SD) at 10 to 14 days postoperatively. Fifty-three patients took none. The authors also found that patients who took more opioid pills had higher VAS pain scores and lower satisfaction. This study suggests that patient satisfaction is not necessarily compromised by adhering to opioid-limiting protocol. Other studies have demonstrated that high satisfaction can be achieved without prescribing postoperative opioids.[27,28]

Our study is not without limitations. First, we report on opioid filling quantities rather than opioid prescription or consumption quantities. This outcome reflects prescriber intent and all other factors around a patient's decision to fill a prescription. Nonetheless, it is reasonable to assume that the trends noted in this study reflect trends in prescriber practice. Second, this analysis is not sufficient to make conclusions regarding the effects of specific types of legislation. Prescription policies, prescriber education, patient expectations, and other factors at local and national levels likely have complex interactions that prevent causal inferences to be drawn regarding the effect of specific legislation on opioid outcomes. In addition, although we excluded patients with concomitant distal radius fracture fixation (likely acute CTR in setting of distal radius fracture), it is possible that patients had other bony or soft-tissue procedures at the time of CTR. These patients may have higher opioid demand. This study is also susceptible to the limitations inherent to all studies involving large national databases with potential for unrecognized inaccuracies or systematic reporting errors. In particular, we chose to adjust for CCI, which may not accurately reflect comorbidity burden if underlying coding is inaccurate. However, we anticipate that comorbidity codes would be missing at random and would not systematically bias study results. Furthermore, psychiatric risk factors for increased opioid demand, such as history of substance use, depression, and anxiety, were not specifically evaluated. These factors could have important roles in opioid demand after CTR. However, we included preoperative opioid use, which has been demonstrated to be a major determinant of postoperative opioid use, in adjusted analyses. Finally, CTR is only one of many high-volume elective orthopaedic surgeries. Other procedures such as total joint arthroplasty and spine surgery may contribute more by volume to the collective opioid overuse in this country.

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