New Persistent Opioid use After Orthopaedic Foot and Ankle Surgery

A Study of 348 Patients

Emily E. Hejna, MPH; Nasima Mehraban, MD; George B. Holmes, Jr, MD; Johnny L. Lin, MD; Simon Lee, MD; Kamran S. Hamid, MD, MPH; Daniel D. Bohl, MD, MPH


J Am Acad Orthop Surg. 2021;29(16):e820-e825. 

In This Article

Abstract and Introduction


Introduction: The opioid epidemic is a devastating public health issue to which orthopaedic surgery is inextricably linked. The purpose of this study was to identify risk factors for new persistent opioid use after orthopaedic foot and ankle surgery among patients who were opioid naive preoperatively.

Methods: Patients undergoing orthopaedic foot or ankle surgery at a single institution were identified. Our state's prescription monitoring program was used to track opioid prescriptions filled in the preoperative (6 months to 30 days before surgery), perioperative (30 days before to 14 days after), and postoperative (2 to 6 months after) periods. Patients filling a prescription during the preoperative period were excluded. Baseline characteristics, surgical characteristics, and perioperative morphine milligram equivalents were tested for association with new persistent use during the postoperative period.

Results: A total of 348 opioid-naive patients met the inclusion criteria. Overall, the rate of new persistent postoperative opioid use was 8.9%. Patients reporting recreational drug use had the highest risk, at 26.7% (relative risk [RR] = 3.3, 95% confidence interval, 1.3 to 8.2, P = 0.0141). In addition, patients who had perioperative opioid prescription >160 morphine milligram equivalents were at increased risk (RR = 2.2, 95% confidence interval, 1.1 to 4.5, P = 0.021). Other risk factors included age ≥40 years (RR = 2.2, P = 0.049) and consumption of ≥6 alcoholic beverages per week (RR = 2.1, P = 0.040). New persistent use was not associated with ankle/hindfoot surgery (versus midfoot/forefoot), bone surgery (versus soft-tissue), or chronic condition (versus acute; P > 0.05).

Conclusion: The rate of new persistent postoperative opioid use after orthopaedic foot and ankle surgery is high, at 8.9%. Greater perioperative opioid prescription is a risk factor for new persistent use and is modifiable. Other risk factors include recreational drug use, greater alcohol use, and greater age. Orthopaedic foot and ankle surgeons should limit perioperative prescriptions and be cognizant of these other risk factors to limit the negative effects of opioid prescriptions on their patients and communities.

Level of Evidence: Level III


In the 1990s, the US FDA approved the use of oxycodone, a prescription opioid. Society was moving toward a more empathetic approach to pain. Accordingly, physicians who were unwilling to prescribe opioids were seen as having opiophobia or being unsympathetic.[1] Following this, opioid sales and prescriptions rose dramatically. In 1991, an estimated 76 million prescriptions for opioid medications were written in the United States.[1] In 2014, this number rose to 245 million.[2] The increase and misuse of opioid prescriptions in concert with the increase in heroin use is now known as the opioid epidemic.

Although concerns regarding opioid overuse are present throughout medicine, surgical specialties are known as particularly heavy prescribers in their management of acute postoperative pain. Of the surgical specialties, orthopaedic surgery ranks among the highest in total opioids prescribed.[3–6]

Although short-term opioids are beneficial for postinjury and postoperative pain relief, a culture of overprescribing may contribute to unintended cases of sustained and harmful long-term use. Most concerning among these cases are the opioid-naive patients who may become dependent in the months following a surgical procedure. Understanding risk factors for new persistent postoperative use is therefore helpful when treating opioid-naive surgical patients.

The purpose of this study was to identify the rate and risk factors for new persistent opioid use in opioid-naive patients after orthopaedic foot and ankle surgery. Based on existing literature from other specialties, we hypothesized that comorbid medical conditions, substance use, specific surgical indications, and greater opioid dispensation during the perioperative period would be positively associated with new persistent opioid use in the postoperative period.