Opioids and Neuropathic Pain Medication Use in Patients with Brachial Plexus Injuries
Christopher Dy, MD, MPH; Kate Peacock, BS; Margaret A Olsen, PhD, MPH; Wilson Z Ray, MD; David M Brogan, MD, MSc
Washington University School of Medicine, St. Louis, MO
Hypothesis: Little is known about the frequency and risk factors for long-term use of opiates and neuropathic pain medications among patients with brachial plexus injuries (BPI). We hypothesized that patients with preoperative opiate prescriptions and diagnoses of depression, substance use, and post-traumatic stress disorder would be at increased risk for continuous opiate prescriptions after BPI surgery.
Methods: Using an administrative claims database of privately-insured patients, we assembled a cohort of patients who underwent BPI surgery (n=1156; procedure+diagnosis codes confirmed). An age- and sex-matched control group of non-BPI patients was also created (n=11,600 ; 3:1 to 5:1 frequency-match depending on age group). All patients included had a >1-year health insurance and prescription drug coverage prior to, and through, 90 days after surgery. Pharmacy claims for prescriptions filled for opioids (including codeine, morphine, methadone, oxycodone, hydrocodone) and neuropathic pain medications (including gabapentin, pregabalin, amitriptyline, nortriptyline, duloxetine, and venlafaxine) were examined from 1 year before surgery to 90 days after surgery.
Results: Among the 1,156 patients undergoing BPI surgery, 27.4% filled an opiate prescription within 30 days before surgery and 9.2% had continuous opiate prescriptions in the 90 days after surgery. In the control group, the frequency of continuous opiate prescriptions was 1.1 %. Among the BPI surgery patients, the frequency of continuous neuropathic pain prescriptions in the 90 days after surgery was 8.7%.
After adjustment for age and sex, significant predictors of continuous postoperative opiate use in BPI patients were preoperative opiate use (OR 8.0; 95%CI 4.8, 13.3), history of drug abuse (OR 5.2; 95%CI 2.0, 13.5), preoperative neuropathic pain medication use (OR 3.3; 95%CI 2.0, 5.6), history of tobacco use (OR 2.3; 95%CI 1.3, 4.2), and diagnosis of anxiety (OR 2.3; 95%CI 1.3, 4.2).
Conclusions: While it is intuitive that patients with a debilitating nerve injury would have more chronic pain, it is helpful to quantify the extent of this issue. Identifying significant risk factors for continuous postoperative opiate use after BPI surgery can aid health care providers in minimizing the chances of chronic opiate use. Our findings suggest that greater attention should be directed to psychosocial factors that increase the risk of continuous opiate use. Integrated multidisciplinary care from pharmacologic, surgical, and rehabilitation-based perspectives allows the development of comprehensive treatment plans that provide pain relief but also address the psychosocial factors that contribute to ongoing neuropathic pain.
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