#.53'9+,,+8954$4/<+89/:?#.53'9+,,+8954$4/<+89/:?
+,,+8954/-/:'2533549+,,+8954/-/:'2533549
!5:.3'449:/:;:+');2:? '6+89 !5:.3'449:/:;:+
8596+):/<+<'2;':/545,6/5/*$:/2/@':/54,:+8$66+8 8596+):/<+<'2;':/545,6/5/*$:/2/@':/54,:+8$66+8
>:8+3/:?";8-/)'2 85)+*;8+9*+4:/,?/4-549;36:/54 '::+849>:8+3/:?";8-/)'2 85)+*;8+9*+4:/,?/4-549;36:/54 '::+849
'4*+:+83/4/4- 8+9)8/(/4-;/*+2/4+9'4*+:+83/4/4- 8+9)8/(/4-;/*+2/4+9
'?5;4-/3
#.53'9+,,+8954$4/<+89/:?
54'9':@54
#.53'9+,,+8954$4/<+89/:?
')1((5;*/
#.53'9+,,+8954$4/<+89/:?
.8/9:56.+854+9
#.53'9+,,+8954$4/<+89/:?
%/22/'3/816':8/)1
#.53'9+,,+8954$4/<+89/:?
"++4+>:6'-+,58'**/:/54'2';:.589
5225=:./9'4*'**/:/54'2=5819':.::690*)0+,,+8954+*;85:.3'4&/49:/:;:+
'8:5,:.+8:.56+*/)9533549
+:;9145=.5='))+99:5:./9*5);3+4:(+4+A:9?5;
!+)533+4*+*/:':/54!+)533+4*+*/:':/54
/3'?5;4-':@5454'9((5;*/')154+9.8/9:56.+8/816':8/)1%/22/'3
+/4(+88?.'82+9/998+*+8/);:91?+</4%'4-'81'2:+4,58:/:).+22'4*
2?'99/, 8596+):/<+<'2;':/545,6/5/*$:/2/@':/54,:+8$66+8>:8+3/:?";8-/)'2
85)+*;8+9*+4:/,?/4-549;36:/54 '::+849'4*+:+83/4/4- 8+9)8/(/4-;/*+2/4+9
!5:.3'449:/:;:+');2:? '6+89
'6+8
.::690*)0+,,+8954+*;85:.3'4&/49:/:;:+
#./98:/)2+/9(85;-.::5?5;,58,8++'4*56+4'))+99(?:.++,,+8954/-/:'2533549#.++,,+8954/-/:'2
533549/9'9+8</)+5,#.53'9+,,+8954$4/<+89/:?9+4:+8,58#+')./4-'4*+'84/4-##.+533549/9
'9.5=)'9+,58+,,+8954(5519'4*05;84'296++88+</+=+*9).52'82?6;(2/)':/549;4/7;+./9:58/)'2)522+):/549
,853:.+$4/<+89/:?'8)./<+9'4*:+')./4-:5529#.++,,+8954/-/:'2533549'225=98+9+'8).+89'4*/4:+8+9:+*
8+'*+89'4?=.+8+/4:.+=582*:52+'84'(5;:'4*1++6;6:5*':+=/:.+,,+89549).52'89./6#./9'8:/)2+.'9(++4
'))+6:+*,58/4)2;9/54/4!5:.3'449:/:;:+');2:? '6+89(?'4';:.58/@+*'*3/4/9:8':585,:.++,,+8954/-/:'2
53354958358+/4,583':/5462+'9+)54:'):+,,+8954/-/:'25335490+,,+8954+*;
;:.589;:.589
'?5;4-/354'9':@54')1((5;*/.8/9:56.+854+9%/22/'3/816':8/)1.'82+9
+/4(+88?8+*+8/)/99+</4;:91?'81%'4-/:).+22'2:+4,58:'4*9/,2?'9
#./9'8:/)2+/9'<'/2'(2+':+,,+8954/-/:'2533549.::690*)0+,,+8954+*;85:.3'4&/49:/:;:+
the
Orthopaedic
forum
A Prospective Evaluation of Opioid Utilization After
Upper-Extremity Surgical Procedures: Identifying
Consumption Patterns and Determining
Prescribing Guidelines
Nayoung Kim, BS, Jonas L. Matzon, MD, Jack Abboudi, MD, Christopher Jones, MD, William Kirkpatrick, MD,
Charles F. Leinberry, MD, Frederic E. Liss, MD, Kevin F. Lutsky, MD, Mark L. Wang, MD, PhD,
Mitchell Maltenfort, PhD, and Asif M. Ilyas, MD
Investigation performed at the Rothman Institute at the Thomas Jefferson University, Philadelphia, Pennsylvania
Background: Although adequate management of postoperative pain with oral analgesics is an important aspect of
surgical procedures, inadvertent overprescribing can lead to excess availability of opioids in the community for potential
diversion. The purpose of our study was to prospectively evaluate opioid consumption following outpatient upper-ex-
tremity surgical procedures to determine opioid utilization patterns and to develop prescribing guidelines.
Methods: All patients undergoing outpatient upper-extremity surgical procedures over a consecutive 6-month period
had the following prospective data collected: patient demographic characteristics, surgical details, anesthesia type, and
opioid prescription and consumption patterns. Analysis of variance and post hoc comparisons were performed using
t tests, with the p value for multiple pairwise tests adjusted by the Bonferroni correction.
Results: A total of 1,416 patients with a mean age of 56 years (range, 18 to 93 years) were included in the study.
Surgeons prescribed a mean total of 24 pills, and patients reported consuming a mean total of 8.1 pills, resulting in a
utilization rate of 34%. Patients undergoing soft-tissue procedures reported requiring fewer opioids (5.1 pills for 2.2
days) compared with fracture surgical procedures (13.0 pills for 4.5 days) or joint procedures (14.5 pills for 5.0 days)
(p < 0.001). Patients who underwent wrist surgical procedures required a mean number of 7.5 pills for 3.1 days and those
continued
Peer review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also re viewed
by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication.
Final corrections and clari fications o ccurred during one or more exchanges be tween the author(s) and copyeditors.
Disclosure: There was no external funding source for this investigation. The Disclosure of Potential Conflicts of Interest forms are provided with the online
version of the article.
e89(1)
COPYRIGHT Ó 2016 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED
J Bone Joint Surg Am. 2016;98:e89(1-9)
d
http://dx.doi.org/10.2106/JBJS.15.00614
who underwent hand surgical procedures required a mean number of 7.7 pills for 2.9 days, compared with patients who
underwent forearm or elbow surgical procedures (11.1 pills) and those who underwent upper arm or shoulder surgical
procedures (22.0 pills) (p < 0.01). Procedure type, anatomic location, anesthesia type, age, and type of insurance were
also all signifi cantly associated with reported opioid consumption (p < 0.001).
Conclusions: In this large, prospective evaluation of postoperative opioid consumption, we found that patients
are being prescribed approximately 3 times greater opioid medications than needed following upper-extremity
surgical procedures. We have provided general prescribing guidelines, and we recommend that surgeons care-
fully examine their patients’ opioid utilization and consider customizing their opioid prescriptions on the basis of
anatomic location and procedure type to prescribe the optimal amount of opioids while avoiding dissemination of
excess opioids.
Although effective postoperative pain control is important,
the U.S. Centers for Disease Control and Prevention (CDC)
has repo rted that t here is a growing epidemic of prescripti on
painkiller abuse
1
. In 2007 alone, there were 27,658 accidental
de aths related to prescription opioid ove rdose
2
. Furthermore,
according to the American Societ y of Consultant Pharmacists,
millions of pounds of “leftover” prescriptions go unused in
patients’ medicine c abinets each year in the United States
3
.
Many factors contribute to this problem, including an in-
creasingly aggressive culture of pain management, a lack of
prescribing guidelines for physicians, inconsistent per iopera-
tive utilization of local anesthetics, and inadequate disposal
instructions for patients
4
.
Orthopaedic surgica l pro cedures pose a unique chal-
lenge and opportun ity in safe pain m anagement. Speci fically,
orthop aedic surgical procedures often result in greater post-
operative pain than other surgical procedures because of
the manipulation of musculoskeletal tissue
5
.Orthopaedic
su rgeon s rou tinely prescribe opioids for postoperative pain
management, yet little is k nown about the typical opioid re-
quirements for various orthopaedic procedures. During a
2014 Amer ican Academy of Or thopaedic Surgeons (AAOS)
symposiu m, it was recognized through an aud ience sur vey
that most orthopaedic surgeons do not know how many pills
to prescribe to their patients and/or how many pills their
patients actually take
6
. This may result in inconsis tent and
often excessive opioid-prescribing patter ns. A greater under-
standing of opioid consumption patterns can result in more
optimal and safer prescribing habits by physicians and can
decrease the risk for overprescribing and potential diversion
or abuse.
The pur pose of our s tudy was to prospectively eval-
uate opioid consumption following outpatient upper-
extremity surgical procedures. The goal was to determine
opioid utilization patterns to help to develop prescribing
guidelines.
Materials and Methods
After obtaining institutional review board approval, 9 hand surgery fellowship-
trained, board-certified orthopaedic surgeons practicing in a single private
academic group prospectively collected postoperative opioid consumption data
for 6 consecutive months (in April 2014 to October 2014). Data were collected
via a standardized intake form. The surgeons were not blinded, were asked to
continue their normal prescribing patterns, and were aware that the patients
would be asked about their opioid consumption postoperatively. Nicotine use
information was not collected. On the day of the surgical procedure, the sur-
geon recorded the following variables on the intake form: the patient’s age and
sex, the procedure’s anatomic location (hand or wrist, forearm or elbow, and
upper arm or shoulder), the procedure type (soft-tissue surgical procedure,
joint surgical procedure, or fracture surgical procedure), the anesthesia type
(local, sedation, general, and/or regional), the opioid type prescribed, and the
quantity of the opioid prescribed.
Patients were included if they had an outpatient surgical procedure of
the hand, wrist, elbow, forearm, or shoulder. Patients undergoing inpatient
procedures were excluded. At the first postoperative visit, the following data
were solicited directly from the patient by a member of the research team and
were added to the standardized intake form: the quantity of the prescribed
opioid used, the total days of opioid use, the reason for discontinuation (the
opioids no longer being necessary or the side effects associated with the opi-
oids), and the side effects (if any). Finally, patients were asked if opioid disposal
instructions were given to them at any point in time. A research team member
collected the intake form, and the data were subsequently entered into a central
database.
The opioids prescribed and studied in this study included Percocet
(oxycodone and acetaminophen) or an oxycodone 5-mg equivalent, Vicodin
(acetaminophen and hydrocodone) or a hydrocodone 5-mg equivalent, and
Tylenol #3 (acetaminophen and codeine) with 30 mg of codeine. For the pur-
poses of this study, each of these prescription opioid pills was treated as equiv-
alent to the other.
The follow ing surgical data were collected: the type of proce dure and
the type of anesthesia. The type of procedure was subcatego rized as a soft-
tissue procedure (i.e., carpal tunnel or tr igger finger release), fracture proce-
dure (i.e ., any frac ture reduction with internal fixation), or joint procedure
(i.e., arthroscopy, arthrodesis, or arthroplasty). The types of anesthesia were
divided into local anesthesia, local ane sthesia with sedatio n, regional anes-
the sia with or without sedation, and gen eral anesthesia. Finally, patient de-
mographic characteristics, such as age, sex, and type of insu rance, were also
collected.
Statistical Analysis
The overall data were examined by descriptive statistics between the means.
The mean number of pills used and the mean total number of days used w ere
calculated on the basis of patient demog raphic characteristics (age, sex, and
insurance t y pe), procedure, anesthesia, injection, and volume of injection.
The percentage of the total prescrip tion used was c alculated by dividing the
number of pills taken by the total number of pills prescr ibed. Singl e-factor
analysis of variance (ANOVA) was conducted to assess significance (p < 0.05)
between the categorical variables and the continuous variables (number
of pills and number of days). Post hoc comparisons were performed usi ng
e89(2)
THE JOURNAL OF B ONE &JOINT SURGERY
d
JBJS.ORG
VOLUME 98-A
d
NUMBER 20
d
OCTOBER 19, 2016
APROSPECTIVE EVA LUAT I O N O F OPIOID UTILIZATION AFTER
UPPER-EXTREMITY SURGICAL PROCEDURES
t tests, with the p value for m ultiple pairwise tests adjusted by the Bonfer roni
correction.
Results
A total of 1,416 patients (639 male patients and 777 female
patients) with a mean age of 56 years (range, 1 8 to 93 years)
were included (Table I). Surgeons prescribed a mean total of
24 pills (median, 20 pills [range, 0 to 110 pills]) per surgical
procedure. Overall, the mean postoperative reported opioid
consumption was 8 .1 pills (median, 4 pills [range, 0 to 90
pills]) for a mean time of 3.1 days, resulting in a utiliz ation
rate of 34% .
Overall Opioid Consumption Pattern
Overall, 28.3% of patients did not take any of their prescribed
medications. An additional 56.1% of patie nts voluntarily dis-
continued the use of their prescription prior to its completion.
In contrast, 11.0% of patients completed the entirety of their
prescription, and 0.6% were still taking their medication at the
time of their first postoperative visit. Finally, 4.0% did not wish
to participate and did not respond.
Opioid Consumption by Age
The mean reported number of opioid pills consumed was
highest(13.4pills)amongpatientsintheagegroupof30
TABLE I Summary of Opioids Taken on the Basis of the Collected Variables
Category
No. of
Patients
No. with Data
on Pills
Mean No. of
Pills Taken
No. with Data
on Days
Mean No. of
Days Pills
Were Taken
Percentage of
Pills Taken
Age group
18 to 19 yr 20 20 12.7 20 5.0 57.3
20 to 29 yr 103 102 12.7 98 4.1 45.8
30 to 39 yr 120 120 13.4 111 4.9 47.3
40 to 49 yr 200 199 10.0 186 3.6 29.8
50 to 59 yr 335 329 8.4 302 3.2 27.7
60 to 69 yr 335 332 6.8 308 2.6 21.7
70 to 79 yr 215 212 4.6 198 2.1 19.9
80 to 89 yr 84 81 3.2 73 1.6 12.8
90 to 100 yr 4 4 12.8 4 4.8 43.3
Sex
Female 777 769 7.9 712 2.9 25.8
Male 639 631 8.6 589 3.4 30.8
Insurance
Private 910 900 8.1 840 4.7 27.9
Medicare 372 367 5.4 340 3.0 19.8
Automotive Association 10 10 13.1 10 4.6 45.3
Workers’ Compensation 116 113 16.0 103 7.2 52
Self-pay or Medicaid 8 8 25.6 8 7.5 66
Procedure type
Soft tissue 904 893 5.1 839 2.2 20.9
Fracture 260 257 13.0 243 4.5 39.4
Joint 252 242 14.5 252 5.0 46.4
Procedure location
Hand 593 586 7.7 557 2.9 27
Wrist 658 651 7.5 600 3.1 27
Elbow or forearm 141 141 11.1 128 4.0 35
Upper arm or shoulder 24 23 22.0 14 6.0 56.6
Anesthesia*
Local 286 285 4.5 250 2.0 16.3
Local with sedation 601 590 5.7 542 2.6 25
Regional 172 172 15.0 151 4.8 42.7
General 337 333 12.5 315 4.0 38.2
*Twenty patients did not undergo any anesthesia.
e89(3)
THE JOURNAL OF B ONE &JOINT SURGERY
d
JBJS.ORG
VOLUME 98-A
d
NUMBER 20
d
OCTOBER 19, 2016
APROSPECTIVE EVA LUAT I O N O F OPIOID UTILIZATION AFTER
UPPER-EXTREMITY SURGICAL PROCEDURES
