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Gossett et al	
Table 3.  Distribution of Total Opioid Dose Prescribed During the Peritreatment Period.a
N

Mean

Standard Deviation

Median

Lower Quartile

Upper Quartile

13 088

488.3

422.2

400

200

650

a

Values given in mg, unless otherwise stated.

Stable ankle fractures are most commonly treated nonoperatively, while unstable fracture patterns often represent
more severe bony and soft tissue injuries and require operative fixation.12 In our analysis, we sought to compare how
injury severity might affect persistent opioid use by comparing surgical treatment of common unstable fracture patterns with a non-operatively treated stable ankle fracture.
Overall, the surgical cohort demonstrated a significantly
higher new persistent use rate; however, only 2 surgical
treatment subtypes, open treatment of bimalleolar ankle
fracture (9.5%) and open treatment of trimalleolar ankle
fracture with fixation of posterior lip (10.4%), demonstrated
significantly higher adjusted new persistent opioid use rates
compared with the nonoperative control group (7.4%).
While this may suggest a slight trend toward persistent opioid use being related to injury severity or procedure type, no
definitive conclusions may be drawn. Brummett et al
showed that the initial amount of opioid prescribed and
patient factors may be more related to persistent opioid use
after surgery than the severity of the procedure.7 It has also
been reported that new persistent opioid use was unrelated
to the postoperative change in pain intensity in hip and knee
arthroplasty patients, which again suggests that persistent
opioid use may not be related primarily to surgical pain.21
OME is a conversion that allows the standardized, quantifiable comparison between the dose of opioids prescribed
with that of different medications. Our study showed that
patients who received an initial opioid dose of 650 mg OME
or greater (top 25th percentile of opioid dose) during the
peritreatment period were 1.5 times more likely to have persistent opioid use, representing the single highest modifiable
risk factor for this cohort. Additionally, patients who underwent surgical treatment of an ankle fracture were nearly 10
times more likely than the nonoperative cohort to receive an
OME dose of greater than 650 mg in the peritreatment
period. This OME value, equivalent to 87 dispensed tablets
of 5 mg oxycodone or 130 tablets of 5 mg hydrocodone, is a
relatively substantial amount. A large initial narcotic dose
has been shown to be related to persistent opioid use.7,16,19,34
While the highest reported risk of persistent opioid use was
among patients who were prescribed between 400 and 799
mg OME, even patients receiving an OME dose as small as
90 mg have been linked to developing new persistent use.30
Given that the initial quantity of prescribed opiates has a
clear impact on long-term opioid use, it is especially unfortunate that physicians tend to overprescribe narcotics when
compared with the actual quantity consumed by patients.6,15,25

The rationale for providers overprescribing narcotics is
likely based on the assumption that this will mitigate refill
requests and increase patient satisfaction. Interestingly, the
amount of opioids prescribed may be unrelated to either of
those factors, and so this increased rate of new persistent
opioid use may not be linked to any clear benefit for the
patient or the provider.5,6
Persistent opioid use following surgery is a complex
and multifaceted problem, requiring a multidisciplinary
solution. Providers must first be able to identify risk factors for persistent opioid use to counsel at-risk patients.
While preoperative opioid use has been shown to be the
strongest predictor of postoperative opioid dependence,
our study focused on relevant factors in opioid-naïve
patients.5 Tobacco use, substance abuse, mental health disorders, comorbid conditions, and lower income have been
repeatedly identified as risk factors for continued opioid
use. 4,7,13,19,21,27,35 In addition to these established risk factors, our results suggest that female sex may be associated
with a higher risk of persistent opioid use, while younger
age (18-34 years) and median household income of
$100 000 or greater was associated with a lower rate of
new persistent use compared with the respective reference
groups. Interestingly, in this cohort, a previously established diagnosis of arthritis was associated with lower
rates of continued opioid use, while certain pain disorders
have been previously identified as risk factors for chronic
opioid use.4,7,13,21,27,35 Identifying and educating these atrisk patients may prove to be a valuable target to reduce
chronic opioid use.
This study has several limitations. This is a retrospective
review of a population that only included insured adults and
their dependents between 18 and 64 years old. Our results
may underestimate new persistent opioid use, as they may
not accurately estimate the rates of the uninsured, underinsured, or elderly populations. Additionally, we assumed that
patients who continued to fill opioids between 91 and 180
days postoperatively had protracted opioid use. We did not
account for possible diversion events or the quantity of opioids truly consumed. Given that these patients sustained a
traumatic injury, it is possible that opioid use was related to
a concomitant injury or diagnosis that could not be
accounted for in this model. We attempted to mitigate this
risk by excluding patients who underwent additional procedures requiring anesthesia on the same day or during the
postoperative period, as well as excluding patients with a
diagnosis of multiple trauma. Finally, closed treatment of
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