Abstract
Purpose
This study compared postoperative opioid utilization between patients with and without preoperative diagnoses of anxiety and/or depression undergoing elective upper-extremity surgery. We hypothesized that patients with these diagnoses would fill more opioid prescriptions within 30 days of surgery than those without.
Methods
We conducted a retrospective analysis using the PearlDiver Mariner Patient Claims Database (2010–2021). Patients undergoing carpal tunnel release, cubital tunnel release, trigger finger release, and epicondylitis surgeries were identified via Current Procedural Technology and International Classification of Diseases-Ninth and Tenth Revision codes. Patients were categorized by diagnosis of depression only, anxiety only, both anxiety and depression, and control. The primary outcome was opioid prescriptions filled within 30 days postsurgery. Descriptive statistics and chi-square tests were employed.
Results
Among 4,166,706 carpal tunnel release patients, 22.4% with a diagnosis of anxiety and/or depression had a higher opioid fill rate (1.85%) than the control group (1.38%). For 1,409,802 trigger finger release patients, 20.7% with a diagnosis of anxiety and/or depression had a higher fill rate (1.62% vs 1.19%). In 913,929 cubital tunnel release patients, 23.0% with a diagnosis of anxiety and/or depression had a higher fill rate (2.41% vs 1.25%). Among 1,645,767 lateral epicondylitis surgeries, 22.2% with a diagnosis of anxiety and/or depression had a higher fill rate (1.04% vs 0.71%). For 397,916 medial epicondylitis patients, 22.2% with a diagnosis of anxiety and/or depression had a higher fill rate (0.92% vs 0.66%).
Conclusions
Preoperative depression and/or anxiety were linked to higher postoperative opioid prescriptions across all surgeries, emphasizing the need to consider these diagnoses in opioid prescribing.
Level of evidence
Prognostic IV.
Key words: Anxiety, Depression, Mental health, Opioid, Pain
Hand and upper-extremity surgeries are highly prevalent. Elective procedures including carpal tunnel release (CTR) have steadily increased over the years, with a 38% increase from 1996 to 2006.1 At the same time, there is a continued epidemic regarding opioid misuse in the United States, with an estimated 9.9 million people reporting prescription opioid misuse.2 Responsible opioid stewardship is of particular importance in orthopedics because hand surgeons are the third highest prescribers of opioids among physicians.3 With regard to upper-extremity surgery, patients are often prescribed more opioids than needed, and patients’ opioid requirements differ based on anatomic location, procedure type, and age, among other factors.4 Therefore, examining patient factors that may be predictive of postoperative opioid utilization is of utmost importance in responsibly prescribing opioids to patients after upper-extremity surgery.
One such factor that has been previously examined is mental health diagnosis, with studies reporting varying findings in terms of psychiatric comorbidities and association with postoperative opioid utilization. Lavoi-Gagne et al5 reported that psychiatric comorbidities are associated with increased opioid use after hand surgery. In examining upper-extremity trauma surgery, mental health and substance use disorders were significant predictors of perioperative opioid demand.6 In addition, patients with higher pain catastrophizing scores used more opioids following ambulatory hand surgeries.7 However, other studies have found no significant difference in postoperative opioid utilization in patients based on psychiatric comorbidities for certain orthopedic procedures.8 Given the lack of consensus regarding the impact of diagnosis of anxiety and/or depression on postoperative opioid use, there remains a need to further examine this association in patients undergoing elective upper-extremity surgery.
Therefore, the purpose of our study was to analyze and compare postoperative opioid utilization in patients with and without a preoperative diagnosis of anxiety and/or depression undergoing elective upper-extremity surgery. We hypothesized that those with a diagnosis of anxiety and/or depression would fill a greater number of opioid prescriptions within 30 days of surgery than those without a mental health diagnosis.
Materials and Methods
This study was performed as a retrospective study using the PearlDiver Mariner Patient Claims Database (PearlDiver Technologies). PearlDiver is a proprietary web-based research platform that uses adjudicated medical claims data from a national repository of commercial, Medicare, Medicaid, government, and cash payer types. There were more than 161 million Health Insurance Portability and Accountability Act complaint records available within the database spanning from 2010 to 2021, when this study was performed. Patients were identified using both Current Procedural Technology and International Classification of Diseases-Ninth and Tenth Revision (ICD-9 and ICD-10) codes. Data were provided in aggregated form to ensure all protected health information was inaccessible; any sample with fewer than 11 individuals was not provided from the database. This study was classified as “Not Human Subject Research” by our institution’s institutional review board.
Patients who underwent surgical procedures for carpal tunnel syndrome, cubital tunnel syndrome, trigger finger, or medial or lateral epicondylitis were queried within the orthopedic subgroup within PearlDiver from January 1, 2010, to December 31, 2019. These procedures were chosen as they represent some of the most common procedures performed by hand surgeons. Data from 2020 and 2021 were intentionally removed from this study to reduce confounding results caused by the coronavirus disease 2019 pandemic. Patients were identified using ICD-9 and ICD-10 diagnosis codes to ensure that the patients had been formally diagnosed for one of the five pathologies of interest for this study (Table 1). The surgically treated individuals were then identified using Current Procedural Technology codes (Table 1). Patient were excluded if they were aged under the age of 18 years at the time of their index procedure, if they had a history of cancer within 1 year (before and after) their index procedure, had a history of dementia, had a concomitant diagnosis related to neurologic disorders, or had a history of drug abuse at any time prior to their index surgical procedure. In addition, data were filtered to ensure that only the first record of the indexed surgical procedure was included to address potential duplicated records caused by repeat or revision surgery. Demographic data were obtained for the final study sample.
Table 1.
Total Number of Patients Who Underwent Five of the Most Common Hand Procedures According to PearlDiver Between 2010 and 2021, as Well as What Proportion Comprised Patients With a Diagnosis of Depression, Anxiety, or Concomitant Depression + Anxiety
| Procedure | Total (N) | Control (N) | Diagnosis of Anxiety and/or Depression (N) |
|---|---|---|---|
| CTR | 4,166,706 | 3,232,732 | 933,974 (22.4%) |
| Trigger finger release | 1,409,802 | 1,118,652 | 291,150 (20.7%) |
| Cubital tunnel release | 913,929 | 703,998 | 209,931 (23.0%) |
| Lateral epicondylitis | 1,645,767 | 1,280,046 | 365,721 (22.2%) |
| Medial epicondylitis | 397,916 | 309,767 | 88,149 (22.2%) |
Patients with a diagnosis of depression or anxiety were identified using both ICD-9 and ICD-10 diagnosis codes (Table 2). Using Boolean language, a total of four study groups were created based on the patients’ diagnoses. The first group (depression group) consisted of patients who only had a diagnosis of depression and excluded all patients with a diagnosis of anxiety. The second group (anxiety group) consisted of patients who only had a diagnosis of anxiety and excluded all patients with a diagnosis of depression. The third group (A&D group) consisted of patients who had a diagnosis of both anxiety and depression. Finally, the fourth group (control group) consisted of patients who did not have a formal prior diagnosis of depression and/or anxiety.
Table 2.
The Rate of Opioid Prescription Prescribed After Surgery Within 30 Days for Patients With or Without a Diagnosis of Anxiety and/or Depression Undergoing Five of the Most Common Hand Procedures
| Procedure | Opioid Rx <30 D After Surgery (Anxiety/Depression Cohort) (%) | Opioid Rx <30 Days After Surgery (Control) (%) | P Value |
|---|---|---|---|
| CTR | 1.85 | 1.35 | <.001 |
| Trigger finger release | 1.62 | 1.19 | <.001 |
| Cubital tunnel release | 2.41 | 1.25 | <.001 |
| Lateral epicondylitis | 1.04 | 0.71 | <.001 |
| Medal epicondylitis | 0.92 | 0.66 | <.001 |
The primary outcome for this study was the total number of opioid prescriptions filled within 30 days of the index surgical procedure. Opioid prescriptions filled were identified within PearlDiver using the Uniform System of Classification (USC) drug database codes (USC-02211, USC-02212, USC-02214, USC-02221, USC-2222, and USC-02232). These codes were recommended by PearlDiver manuals to identify all opioid-based prescriptions. The analysis of opioid-based prescriptions allowed for the identification of the first filling of an opioid prescription following the index surgery, and any subsequent refills filled by patients within the 90 days following the index procedure. Additional variables available included the average morphine milligram equivalents per prescription, as well as the average morphine milligram equivalents per day per prescription.
All statistical analyses were performed using the PearlDiver application. PearlDiver’s native application used R Studio software version 3.6.1. Descriptive statistics were used to describe each study group, and univariate analyses were used to determine baseline differences in demographics between groups. The difference between prescriptions filled between the study groups was assessed using chi-square tests. Given that up to six tests were performed, the adjusted alpha was used to address the potential for type I errors. Therefore, a P value of .008 or less was considered to be a statistically significant finding.
Results
Overall, a total of 4,166,706 were identified as having undergone CTR over this time frame via the PearlDiver query. Of these patients, 933,974 (22.4%) had a previous diagnosis of anxiety (57.5%), depression (13.8%), or both anxiety + depression (28.7%) (Table 1, Fig.). Of these patients with a diagnosis of anxiety and/or depression who underwent CTR, 1.85% (17,298/933,374) filled opioid prescriptions within 30 days after surgery from their surgical date, which was significantly greater than the 1.38% (44,523/3,232,732) of patients in the control group who filled postoperative opioid prescriptions (P ≤ .001) (Table 2).
Figure.
Distribution of diagnoses including anxiety, depression, and anxiety + depression comprising the mental health diagnosis cohort for different upper-extremity procedures.
A total of 1,409,802 patients underwent trigger finger release. Of these, 291,150 patients (20.7%) had a diagnosis of anxiety and/or depression—15.0% of which had a diagnosis of both depression and anxiety, 58.3% had a diagnosis of anxiety alone, and 26.7% had a diagnosis of depression alone (Table 1, Fig.). Of these patients with a diagnosis of anxiety and/or depression who underwent trigger finger release, 1.62% filled opioid prescriptions within 30 days after surgery, which was significantly greater than the 1.19% of patients in the control group (P < .001) (Table 2).
A total of 913,929 patients underwent cubital tunnel release over this time frame, of which 209,931 (23.0%) carried a diagnosis of anxiety and/or depression—29.2% with a diagnosis of both depression and anxiety, 13.6% with depression alone, and 57.2% with anxiety alone (Table 1, Fig.). A significantly greater percentage of patients with a diagnosis of anxiety and/or depression filled an opioid prescription within 30 days after surgery than the control group without a mental health diagnosis (2.41% vs 1.25%, P < .001) (Table 2).
Surgery for lateral epicondylitis was performed on 1,645,767 patients across this time period. A diagnosis of anxiety and/or depression was present in 365,721 (22.2%) patients—27.1% with a diagnosis of both anxiety and depression, 60.2% with a diagnosis of anxiety alone, and 12.7% with a diagnosis of depression alone (Table 1, Fig.). The cohort with a diagnosis of anxiety and/or depression filled opioid prescriptions at a rate of 1.04% within 30 days after surgery, which was significantly higher than the 0.71% of patients in the control group (P < .001) (Table 2).
Surgery for medial epicondylitis was performed on 397,916 patients, of which 88,149 (22.2%) had a diagnosis of anxiety and/or depression. Of the cohort with a diagnosis of anxiety and/or depression, 27.7% of patients had a diagnosis of both anxiety and depression, 59.2% had a diagnosis of anxiety alone, and 13.1% had a diagnosis of depression alone (Table 1, Fig.). The cohort with a diagnosis of anxiety and/or depression filled opioid prescriptions within 30 days after surgery at a significantly higher rate than the control group (0.92% vs 0.66%, P < .001) (Table 2).
Discussion
A sizable proportion of patients undergoing hand and upper-extremity surgeries have a diagnosis of anxiety, depression, or both. Our findings confirm the hypothesis that patients with a diagnosis of anxiety and/or depression undergoing hand surgery were associated with filling a greater number of opioid prescriptions within 30 days after surgery than those without a diagnosis.
Patients who received CTRs reported the second-highest rate of diagnosis of anxiety and/or depression of the five surgery groups, with a proportionately higher rate of opioid prescription-filling than patients without such a diagnosis. A previous study has identified that younger age and female sex were two factors associated with opioid consumption following CTR.9 This may be influenced by CTR patients being prescribed twice the amount of opioid pills consumed, with more recent guidelines recommending 5–10 opioid pills for CTR surgery.9,10 In a recent meta-analysis, patients with depression undergoing CTR experienced increased pain scores, which likely prompted increased opioid intake in the postoperative period.11
Although approximately one fifth of patients who underwent trigger finger release were found to have a diagnosis of anxiety and/or depression, this cohort reported the lowest number of patients with anxiety and depression among the five surgery groups. Previous literature has demonstrated that psychosocial factors including mental health diagnoses impact pain and disability scores in patients undergoing trigger finger releases.12,13 Our study supports these findings, as the trigger finger cohort of patients with a diagnosis of anxiety and/or depression was significantly more likely to fill opioid prescriptions within 30 days from surgery. Although wide awake, local anesthesia, and no tourniquet modalities have emerged to complement soft tissue hand procedures such as trigger finger release, there is no clear relationship at this time between improved pain control and more traditional anesthesia techniques.14,15
The cubital tunnel release cohort had the highest representation of patients with a diagnosis of anxiety and/or depression of the five surgery groups. In a cohort of 246 patients, Jia et al16 reported depression and anxiety in 17.9% and 14.2% of patients, respectively. Our findings show that 13.6% of patients who underwent cubital tunnel release were diagnosed with depression, and 57.2% reported a diagnosis of anxiety. These differences are likely attributed to symptom classification, as the previous study used a self-administered questionnaire called the Hospital Anxiety and Depression Scale.
Limited literature exists regarding the prevalence of mood disorders in patients with lateral epicondylitis. Pensak et al17 reported that mood disorders coexisted in 75% of patients in a small cohort. Our large database study suggests that a diagnosis of anxiety and/or depression has a similar association with lateral epicondylitis as it does with other most common hand pathologies and procedures. Furthermore, patients receiving surgery for medial epicondylitis represented the smallest cohort. To our knowledge, there are no previous studies that examine the prevalence of a diagnosis of anxiety and/or depression in patients with medial epicondylitis. In a study examining the impact of psychosocial factors in patients with medial epicondylitis, mental exhaustion after work was found to have the strongest association.18 These findings highlight the multifaceted nature of psychosocial factors and their impact on outcomes in patients with upper-extremity disorders. Similar to other hand procedures explored in our study, patients with an anxiety and/or depression diagnosis who underwent either lateral or medial epicondylitis surgery were associated with higher rates of postoperative opioid prescriptions than those without such a diagnosis.
There are also limitations specific to the PearlDiver database. As a large private national database, PearlDiver provides deidentified patient data, which do not allow insight into long-term outcomes.19 Although the database can highlight associations over a large number of patients, it is unable to discern potential confounding variables and ultimately prompts future examination including prospective study designs. Furthermore, in an effort to reduce as many confounding variables as possible, very stringent definitions were used for both opioid prescription and patient inclusion. This was an intentional decision to produce the most accurate estimates possible, but the conservative approach used in this study may limit its generalizability to a larger patient population. The database is also designed to observe opioid prescriptions filled, and thus, one potential limitation is that we were unable to assess the amount of opioids actually used. In addition, not all mental health diagnoses were analyzed (bipolar disorder, posttraumatic stress disorder, etc.) in this study. We believe that the focus was better served by analyzing mental health pathology such as depression and anxiety, which are more common in the general population and are consistently explored in similar studies on this topic. One final key limitation of this study is that there was a lack of data on surgeon opioid prescribing practices, specifically which patients may have been treated by surgeons who do not prescribe opioids at all. In lacking this information, our findings may be somewhat skewed because in reality, they may be reflective of a combination of both variation in physician prescribing patterns in addition to patient-driven demand for opioids. For example, patients undergoing surgery by physicians using opioid-free pain regimens would be excluded from opioid usage data, and this may potentially disproportionately affect the control group (ie, patients without a diagnosis of anxiety and/or depression). In these cases, it is possible that patients with a diagnosis of anxiety or depression may seek opioids elsewhere or seek a surgeon willing to prescribe them. This limitation is important to consider as it poses the question as to whether patients with a diagnosis of anxiety or depression have a predisposition to request opioids or whether the observed differences in opioid use may be reflective of differences in provider prescribing practices. Despite these limitations, we believe our findings to be valid.
Overall, we found in a large database study that a preoperative diagnosis of depression and/or anxiety was associated with higher opioid prescription rates in the postoperative period across all five of the most common hand procedures. Further prospective studies could be useful in investigating the effect of mental health diagnoses on postoperative opioid consumption for common hand surgeries. As mentioned previously, future studies may benefit from incorporating surgeon prescribing practices to identify if opioid usage trends are more patient-driven or prescriber-driven. In addition, prospectively tracking opioid use after initial prescription and considering other sources of receiving opioids such as from primary care physicians, emergency department, or pain specialists may be useful in further elucidating opioid usage trends. In implementing these variables, future studies can help more accurately control for potential confounding variables and further assess the impact of mental health diagnoses and opioid usage after hand surgeries.
Statement of Human and Animal Rights
This study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki. No animal subjects were involved in this research.
Statement of Informed Consent
Informed consent was not required as the data were acquired through a publicly available database.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
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