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Science News: Frequency and Risk Factors for Prolonged Opioid Prescriptions After Surgery for Brachial Plexus Injury

Submitted by Rebecca O'Bryan, MD
Edited by Clark Pinyan, MD

Frequency and Risk Factors for Prolonged Opioid Prescriptions After Surgery for Brachial Plexus Injury.
Christopher J. Dy MD, MPH; Kate Peacock BS; Margaret A. Olsen PhD, MPH; Wilson Z. Ray MD; David M.Brogan MD, MS.
The Journal of Hand Surgery Volume 44, Issue 8, August 2019, Pages 662-668.

This article reports the results of an extensive retrospective analysis of data for 1,936 patients that underwent surgery for a brachial plexus injury (BPI) investigating potential identifiable risk factors for prolonged opioid use postoperatively.

The authors reviewed a deidentified database to extract patients with coded brachial plexus injury and subsequent brachial plexus or peripheral nerve surgical intervention. Risk factors included: diagnoses of depression, anxiety, drug abuse, tobacco use, and preoperative use of opioids and neuropathic pain medications.  Control group was formed utilizing patients matched by age, sex and year to provide baseline data regarding opioid and neuropathic pain medication prescribing habits. Multivariate linear regression modeling was employed to examine relationships between the above mentioned factors and prolonged opioid (primary dependent) and neuropathic (secondary dependent) pain medication prescribing. Subgroup analysis evaluated the effect of opioid naïveté).

27% of BPI patients had prolonged opioid prescribing (defined as 90-180 days post index date), with 10.8% of patients opioid naïve prior. Predictors of prolonged postoperative opioid prescriptions in BPI patients were preoperative opioids, preoperative neuropathic pain medication use, histories of drug abuse, tobacco use, and anxiety. Most important factor was determined to be preoperative use opf opioids.

Comments: This article provides detailed statistical information regarding risk factors for potential prolonged opioid prescribing in the brachial plexus injury patient post operatively. Significant questions remain due to the methods employed in identifying and defining the “prolonged opioid prescription” group, as these patients were identified utilizing data from prescriptions filled, not actual data on patient utilization. These prescriptions may not have been utilized, may have been diverted, or may not have been effective. Due to the retrospective nature of this study, no information is available regarding prescriber decision-making and patient outcomes with respect to prescribing of controlled medications. Interestingly, only 12.2% of the BPI patients had prolonged neuropathic pain medication prescriptions. This is attributed to potential poor long-term tolerance of these medications; however, in my experience, this may in fact be due to lack of education or facility in the prescription of these medications by the surgical providers.

Opioids are third line medications in the management of neuropathic pain, and many options can and should be employed in the management of BPI pain prior to their introduction. Identification of risk factors for long term use and potential abuse may help the neuromuscular physician on the team in recommendation of medications for pain management, with the goal of minimizing long term prescription opioids whenever possible. Education of surgical specialists in the use of neuropathic pain medications with lower risk of abuse and dependency would also be beneficial.

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