Impact of Patient-Reported Allergies on Early Postoperative Opioid Use and Outcomes Following Ambulatory Hand Surgery

Abstract

Background: Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Methods: Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. Results: A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition (P < .001) and pain (P < .001) and lower PROMIS mental health scores (P = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, P = .016; week 2, P = .001; total, P = .005). Conclusions: The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.

Introduction

The prescription opioid epidemic in the United States has fallen under great scrutiny. Similarly, surgeon opioid over-prescribing, estimated at an average rate of 2 to 5 times more opioids than patients consume, has increased attention on investigating trends in and risk factors for increased postoperative opioid use.^1,2 Importance has been placed on identifying patient-specific risk factors for increased opioid use, whereby physicians can preoperatively identify patients who may be at risk for chronic opioid consumption and appropriately tailor treatment plans and prescribing habits.^2,3

Psychosocial factors leading to maladaptive coping strategies and increased distress are consistently cited in the literature as risk factors for increased opioid use.^3-5 They have been shown to impact continued opioid use following musculoskeletal injuries. Moreover, Helmerhorst et al ⁶ identified catastrophic thinking as the single best predictor of continued opioid use.

While some patients with clinical depression and anxiety self-report these diagnoses, many do not. Recent orthopedic literature has demonstrated that the number of patient-reported allergies (PRAs) is associated with depression and anxiety.^7,8 Furthermore, nonorthopedic literature suggests a link between PRAs, underlying psychological dysfunction, and psychosomatic burden, including major depression, anxiety, and bipolar disorders. ⁹ Given that PRAs are routinely recorded in the patient chart, this metric may carry utility in identifying risk for postoperative opioid use in settings where maladaptive coping strategies are present, whether or not they have been self-reported.

In orthopedic surgery, several studies have identified relationships between PRAs and poorer outcomes, including increased patient-reported pain levels, length of stay, and hospital admission costs as well as lower functional scores and quality of life following knee arthroplasty, hip arthroplasty, and spine surgery.^7,10-13 However, while prior studies investigated the relationship between PRAs, pain scores, and satisfaction, investigation of PRAs in relation to postoperative opioid use, is lacking.

Thus, the purpose of this study was to investigate the associations between PRAs and: (1) early postoperative opioid consumption; and (2) patient-reported outcomes (pain and satisfaction) following ambulatory hand surgery. We hypothesized that after controlling for other known factors associated with opioid intake, increasing number of PRAs would be associated with increased early postoperative pain, increased number of oral morphine equivalents (OMEs) consumed, and decreased satisfaction following ambulatory hand surgery.

Materials and Methods

Patients and Data Collection

This institutional review board-approved study retrospectively chart reviewed over 150 patients who underwent ambulatory hand surgery at our institution. Retrospective chart review was used to record PRAs. An allergy was considered present if a food, animal/insect, drug-related, or environmental allergy is reported by the patient and documented in the electronic medical record (EMR).

Patients were recruited from 10 hand surgeons at our institution, identified via the preoperative schedule, and screened via telephone the week prior to their surgery. Those meeting the inclusion criteria were asked to participate in the study. Inclusion criteria consisted of: age 18 and older, English speaking (to perform questionnaires over the phone), and primary elective ambulatory hand surgery (bony or soft tissue). The ambulatory hand procedures included in the study are shown in Table 1, separated into 2 tiers based on expected level of postoperative pain. Exclusion criteria included preoperative pain in the ipsilateral upper extremity secondary to another condition separate from the study procedure, allergy or inability to consume opioids, current substance abuse or history of opioid abuse, not opioid naïve (taken opioid in the last 6 weeks), chronic pain/use of chronic pain medication, and fracture cases. Nonelective cases, such as trauma procedures, were excluded due to the rapid scheduling required that prevents patient completion of the study’s preoperative measures, variability in preoperative opioid consumption, pain severity secondary to the traumatic nature of the injury, and possible concomitant injury.

Table 1.

Included Ambulatory Hand Procedures and Respective Tiers.

Tier 1	N	Tier 2	N
Trigger finger release	26	Cubital tunnel release	15
Carpal tunnel release	31	Collateral ligament repair	9
De Quervain’s release	3	Dupuytren’s contracture release	4
Ganglion cyst excision	11	Tendon transfer, tenolysis, tenodesis, tendon centralization/stabilization	19
Arthroscopy	4	Fasciectomy, fasciotomy	6
		Arthrodesis fingers/MCP	9
		Arthroplasty fingers/MCP	13
		Carpectomy, styloidectomy, ulnar shortening	11

Note. MCP = metacarpophalangeal.

Preoperatively, patients agreeing to participate in the study completed the Pain Catastrophizing Scale (PCS) and the Mindfulness Attention Awareness Scale (MAAS). The PCS is a validated questionnaire consisting of 13-items that ask the patients to rate how often they experience each of the pain-related thoughts. ¹⁴ The total score ranges from 0 to 52, where higher scores represent more pain catastrophizing. The MAAS is a validated 15-item scale that assesses mindfulness, receptive awareness, and ability to remain presently focused. ¹⁵ The total score ranges from 1 to 6, where higher scores represent more mindfulness.

Preoperatively, patients also completed the Patient Reported Outcome Measurement Information System (PROMIS) v1.02 Global Health scores, including physical health, mental health, and pain scores. ¹⁶ Scores are normalized such that a PROMIS score of 50 represents the average in a model population, with a standard deviation of 10-points. Higher scores indicate more of the domain being measured. For example, higher physical health PROMIS score indicates greater function.

Postoperatively, all patients received similar postanesthesia care unit discharge instructions, which included taking their prescribed opioids every 4 to 6 hours, as needed. Patients received no standardized counseling about alternative forms of analgesia, the indications for opioid use, or possible side effects of opioid use. Postoperative narcotic prescriptions were tailored to the individual patient and procedure and were also not standardized.

After surgery, all patients were followed for 15 days, during which they logged their pain levels and pain medication intake daily in a pain diary. Patients received a phone call from the research assistant at postoperative days 3, 8, and 15 to obtain outcome measures for each of the preceding days, including numeric rating scale (NRS) pain scores (“On a scale from 0-10, where 0 is the none and 10 is the worst, what was the maximum pain level you felt on post-op day X?”), number of opioid pills taken, number of nonopioid pain pills taken, data on prescription filing and refilling, and patient satisfaction (“How satisfied are you with the pain treatment? 0, not treating the pain/N/A; 1, very dissatisfied; 2, dissatisfied, 3, neutral; 4, satisfied; 5, very satisfied.”). All data were entered into REDCap, a secure electronic database. To allow for comparison across patients with disparate narcotic prescriptions, total opioid pill consumption over the 2-week postoperative period was converted to OME using standard conversion factors. ¹⁷

Retrospective chart review of the EMR was conducted to record basic demographic information, PRAs, and allergic reaction, if available, PROMIS scores at time of preoperative phone call, and surgery details, including procedure length, duration of tourniquet usage, and type of anesthesia. Allergy data can be submitted to the EMR by any provider a patient sees. If the allergy section was populated prior to the patient’s visit to our clinic, the allergies were confirmed at the patient’s clinic visit and again preoperatively by the anesthesia team. All allergies were characterized as self-reported, including allergies without confirmatory testing (eg, skin or patch testing). Allergies were categorized as related to food, drug, animal/insect, or environmental (including seasonal). If available, the associated allergic reaction (rash, hives, itchy throat, or anaphylaxis) was recorded. Drug reactions classified as “sensitivities” were not included.

Modeled on prior methodology, patients were divided into 2 cohorts based on the presence or absence of PRAs: patients with no PRAs (no allergy group; 0 PRA) and patients with one or more PRA (allergy group; ≥1 PRA).^11,12,18,19 A total of 171 charts were reviewed, and 137 met the inclusion criteria. Eleven patients were excluded due to chronic use of opioids, incomplete pain diaries, canceled surgeries, or loss of follow-up. Twenty-three patients were excluded due to reported allergy to opioids. Of the 137 included patients, 64 patients had no PRAs and 73 patients had at least 1 PRA (Figure 1 Supplemental).

Statistical Analysis

Descriptive statistics were used to summarize baseline patient demographics, clinical characteristics, and PRAs. Means and standard deviations are reported for continuous variables. Frequency and percentage are reported for categorical variables. Comparative analysis was conducted between patients with no allergies and patients with at least one allergy. Continuous data were analyzed using nonparametric Mann-Whitney U tests, as they did not meet the assumption of normality based on Kolmogorov-Smirnov tests. Continuous data are reported as means and standard deviations. Categorical data were analyzed using chi-square tests and are reported as frequencies and percentages.

A chi-square analysis was performed to identify relationships between dependent variables (opioid consumption, pain scores, and patient satisfaction at week 1, week 2, and total timepoints) and potential independent variables, including PRAs, sex, age, mental health history, smoking status, PCS score, MAAS score, anesthesia type, and surgery type.

A multivariable linear regression model was used to identify potential risk factors associated with total OME. A multi-iterative stepwise regression technique was used to reduce the model to prevent overfitting and maximizing precision of the parameter estimates of the final model. Variables that achieved a P-value ≤ .10 were retained in the final model while variables that achieved a P-value of .05 or below were considered statistically significant. All analyses were performed using SPSS version 23.0 (IBM Corp, Armonk, NY).

Results

A total of 137 patients who underwent 161 unilateral procedures were included in our study population, where 52.6% (n = 72) were female and the mean age was 59.4 years (range: 22-84) at the time of surgery. A majority of patients (53.3%, n = 73) reported at least 1 PRA (allergy group). Of those 73 patients with at least 1 PRA, there was a total of 168 allergies and an average of 2.3 allergies per person (Figure 2 Supplemental). The maximum number of PRAs was 8. One-third of patients in the allergy group had 1 PRA (n = 24), 41% had 2 PRAs (n = 30), and 25% had 3 or more PRAs. The most commonly reported allergies were to drugs (n = 92, 54.8%), food items (n = 37, 18.7%), animals or insects (n = 10, 5.0%), and environmental stimuli (n = 9, 4.5%). Baseline patient characteristics, including demographics, PCS, MAAS, and PROMIS scores, are summarized in Table 2. The allergy group had significantly higher female composition (P < .001), lower PROMIS v1.2 Mental Health scores (representing lower mental health function) (P = .044), and higher preoperative pain scores (P < .001). While patients with PRAs did have higher pain catastrophizing scores (7.8 versus 6.0), this difference was not statistically significant.

Table 2.

Patient Demographics, Preoperative Scores, and Surgical Details.

Data	0 PRA (n = 64)	≥1 PRA (n = 73)	P value
Demographics
Sex (male/female), n	41/23	24/49	<.001
Age, y	58.3 ± 14.8	60.5 ± 13.5	.300
Psych history (%)	32.1	38.1	.498
Preoperative scores
PROMIS v1.2 MH T-Score	57.2 ± 6.4	54.9 ± 6.3	.044
PROMIS v1.2 PH T-Score	53.5 ± 7.2	51.3 ± 5.1	.075
MAAS score	5.1 ± 0.6	4.8 ± 0.7	.066
PCS score	6.0 ± 5.9	7.8 ± 7.8	.244
Pain	3.1 ± 2.7	4.0 ± 2.6	<.001
Surgical details
Tier (Tier 1/Tier 2), n	24/40	38/35	.088
Length of surgery (min)	71.1 ± 56.6	49.8 ± 43.7	.018
Tourniquet time (min)	52.1 42.1	38.2 ± 36.0	.047
Laterality (right/left)	31/33	46/27	.086
Location, n (%)
Hand	31 (48.4)	36 (49.3)	.918
Wrist/forearm	29 (45.3)	43 (58.9)	.112
Elbow	9 (14.1)	5 (6.8)	.164
Anesthesia, n (%)			.819
Wide awake, with local	13 (20.3)	16 (21.9)
Sedation, with local or regional	51 (79.7)	57 (78.1)

Note. Data are reported as mean ± standard deviation unless otherwise indicated. PRA = patient-reported allergies; PROMIS = Patient Reported Outcome Measurement Information System; MAAS = Mindfulness Awareness Attention Scale; PCS = Pain Catastrophizing Scale.

Bold indicates significant P value < .05.

Table 2 shows the surgical details for each group, including procedure tier, location, length of surgery, tourniquet duration, and anesthesia type. The breakdown of specific surgeries is in Table 1 Supplemental. There were no statistically significant differences in procedure tiers or surgical location between groups. In our sample, the 4 most common procedures performed were carpal tunnel release (n = 31, 22.6%), trigger finger release (n = 26, 19.0%), tendon transfer, stabilization, tenodesis, or tenolysis (n = 19, 13.9%), and cubital tunnel release (n = 15, 11.0%). Patients in the allergy group had significantly shorter procedures (P = .014) and tourniquet times (P = .038). There were no statistically significant differences in type of anesthesia received between groups.

Table 3 shows the opioid prescription data. One-hundred twenty-two patients had opioid prescription data in the EMR. The median number of pills prescribed was 15 (range: 5-40). Oxycodone/acetaminophen was most frequently prescribed (43.4%), followed by hydrocodone/acetaminophen (36.9%), oxycodone (8.2%), and tramadol (7.4%). Ten patients had no prescription on file and 5 patients were not prescribed opioids. There was no significant difference in narcotic prescriptions between groups (P > .05).

Table 3.

Postoperative Opioid Prescriptions.

Opioid prescription	No. of patients (%)*
Opioid type (dosage)
Oxycodone/acetaminophen (5 mg)	53 (43.4)
Hydrocodone/acetaminophen (5 mg)	45 (36.9)
Oxycodone (5 mg)	10 (8.2)
Hydromorphone (2 mg)	3 (2.5)
Hydromorphone (4 mg)	1 (0.8)
Acetaminophen-codeine (30 mg)	1 (0.8)
Tramadol (50 mg)	9 (7.4)
No prescription on file or not prescribed opioids	15
No. pills prescribed
5	18 (14.8)
10	31 (25.4)
15	24 (19.7)
20	28 (23.0)
>20	21 (17.2)

^*Percentage calculated using total opioid prescriptions as denominator (122).

The average total OME consumed postoperatively was 41.2 (range: 0-323) in the no PRA group and 43.8 (range: 0-416) in the PRA group. In terms of average total opioid pills consumed, the no PRA group consumed an average of 6.37 (range: 0-43) opioid pills postoperatively while the PRA group consumed an average of 6.08 (range 0-49) opioid pills postoperatively. This difference was not statistically significant. Patients with at least 1 PRA had significantly higher week 1 pain scores (P = .040) and total pain scores (P = .043). There were no differences in satisfaction among patients with no PRAs and patients with at least 1 PRA, with the exception of week 2 satisfaction where patients with at least 1 PRA had significantly lower scores (P = .018; Table 4). Patients with at least 1 PRA consumed significantly more Tylenol (7.1 vs. 3.2 pills) than the no PRA group in postoperative week 1 (P = .026). By week 2, there was no significant difference in Tylenol consumption between groups (2.7 vs. 2.6 pills, P = .094) (Table 2 Supplemental).

Table 4.

Primary and Secondary Outcomes in Patients With and Without Patient-Reported Allergies.

Secondary Outcomes	0 PRA (n = 64)	≥1 PRA (n = 73)	P value
OME consumption
Week 1	34.8 ± 45.9	41.3 ± 66.8	.928
Week 2	6.4 ± 19.5	4.0 ± 16.7	.968
Total	41.2 ± 59.9	43.8 ± 75.9	.770
Pain
Week 1	2.7 ± 2.3	3.3 ± 2.0	.040
Week 2	1.4 ± 1.9	1.9 ± 2.2	.232
Total	2.1 ± 2.0	2.6 ± 2.0	.043
Satisfaction with pain Tx
Week 1	3.8 ± 1.8	3.9 ± 1.4	.313
Week 2	4.1 ± 1.6	3.8 ± 1.6	.018
Total	3.9 ± 1.6	3.9 ± 1.3	.115

Note. Data reported as mean ± standard deviation; PRA = patient-reported allergies; OME = oral morphine equivalents; Tx = treatment.

Bold indicates significant P value < .05.

Table 5 contains Pearson correlation analyses, which show a significant association between increasing number of PRAs and OME consumption at week 1 (r = 0.204, P = .017) and overall (r = 0.194, P = .023). Within the PRA population, there was a significant correlation between increasing number of PRAs and OME across all time points, week 1 (r = 0.281, P = .016), week 2 (r = 0.386, P = .001), and overall (r = 0.323, P = .005).

Table 5.

Association Between Allergies and OME Consumption.

Variable	Statistics	OME (Week 1)	OME (Week 2)	OME total
Number of allergies	Pearson correlation	0.204	0.132	0.194
(All patients, n = 137)	P value	.017	.124	.023
Number of allergies	Pearson correlation	0.281	0.386*	0.323*
(Allergies only, n = 73)	P value	.016	.001	.005

Note. OME = oral morphine equivalent.

^*P ≤ .005.

Bold indicates significant P value < .05.

After adjusting for potential confounding effects using multivariable regression analysis, the factors independently associated with increased postoperative OME consumption were younger age at surgery, past surgical history, tier 2 surgery, lower PROMIS-10 physical health T-score, and higher PROMIS-10 mental health T-score (Table 6).

Table 6.

Multivariable Regression Model for Factors Associated With Total OME Consumption.

Variable	β	SE	P value
Age at surgery	−1.42	0.59	.019
Past surgical Hx	48.78	27.11	.077
Tier 2 (versus Tier 1)	46.98	17.52	.010
PROMIS-10 Physical Health T-Score	−3.47	1.62	.036
PROMIS-10 Mental Health T-Score	3.30	1.46	.027

Note. PROMIS = Patient Reported Outcome Measurement Information System v1.02; OME = oral morphine equivalent.

Discussion

In the setting of the current opioid epidemic, identifying patients who may be at risk for increased opioid use postoperatively is of extreme importance. Variable findings have been reported studying the impact of PRAs on pain and outcomes following orthopedic surgery. Overall, postoperative opioid use following select ambulatory hand surgery was low. In spite of the small total consumption, we found that younger age, prior surgical history, higher tier surgery, and PROMIS scores were significantly associated with increased postoperative OME consumption. Contrary to our hypothesis, PRAs were not associated with increased postoperative pain or decreased satisfaction. While presence of PRAs was not found to be associated with increased OME consumption, higher numbers of PRAs did correlate with higher OME consumption across all study time points.

PRAs have been associated with worse orthopedic surgery outcomes, including increased pain and decreased satisfaction.^8,10,11,13 That there were no significant differences in average pain or satisfaction scores between the 0 allergy and ≥ 1 allergy group in this study, is in line with existing orthopedic literature using the 0 and ≥ 1 allergy threshold.^18,19 In shoulder arthroplasty, Rosenthal et al ¹⁹ found no difference in forward flexion, visual analog scale (VAS) pain, or satisfaction between patients with and without drug allergies. Furthermore, Nixon et al ¹⁸ reported no difference in PROMIS outcome scores among patients with no allergies and those with at least 1 allergy following foot and ankle surgery. However, as was the case in the present report, most studies that find an association between PRAs and worse postoperative outcomes have used correlation analyses that suggest the quantity of PRAs matters. In hip and knee arthroplasty, each additional PRA was associated with 50% increased odds for poorer quality of life ratings. ¹⁰ In knee arthroplasty, multiple linear regression analysis revealed increasing number of PRAs was significantly associated with worse function, stiffness, and pain scores both at baseline and 2 years postoperatively. ¹⁰ Some studies have found a threshold number of PRAs over which patients have worse outcomes. For example, in lumbar spine surgery, patients with more than 5 PRAs had increased disability as measured by the Oswestry Disability Index and worse VAS pain scores. ⁸ Another study revealed that patients with 4 or more PRAs who underwent knee or hip arthroplasty experienced worse functional outcomes as measured by the physical component of the 36-Item Short Form Health Survey (SF-36) and the functional Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, as well as increased hospital stays. ¹³ These studies highlight the importance in the quantity of PRAs, not the presence or absence of PRAs, when investigating their effect on postoperative outcomes. Contrary to prior literature, our study did not find higher postoperative pain levels or greater dissatisfaction in patients with multiple allergies.

Given the relationship between PRAs and various psychiatric comorbidities, and PRAs’ negative impact on orthopedic surgery outcomes, researchers have suggested that PRAs may be a proxy for mental health, indicating psychological distress and ineffective coping strategies.^{9-11,13,20-25} Thus, PRAs may have clinical relevance in relation to a patient’s underlying mental status, helping to explain the relationship between increased PRAs and higher OME consumption postoperatively. Catastrophization—an exaggerated response to pain with rumination and feelings of helplessness regarding the pain experience—is an important predictor of pain following hand surgery and has been shown to correlate with postoperative opioid consumption.^1,3,6,26 While we did find patients with PRAs had lower baseline mental health functioning, our results showed no association between PRAs and pain catastrophization. Thus, pain catastrophization was not a confounding factor in the relationship between greater PRAs and OME consumption in our study.

With the prescription opioid use epidemic in the United States, attention has turned to investigating trends in postoperative opioid use. ¹ Several factors have been shown to correlate with increased opioid consumption, some of which our study findings confirmed. Younger age has consistently been identified in the literature as a risk factor for increased opioid consumption.^27,28 Additionally, in hand surgery, Kim et al ² and Rodgers et al ²⁹ found significantly higher opioid pill consumption among patients who underwent bony procedures (joint and fracture) compared to soft tissue procedures. This is in line with our finding that tier 2 surgery was associated with greater OME consumption. Furthermore, the presence of medical comorbidities, including heart failure, pulmonary disease, and diabetes, increases the risk for long-term opioid use. ³ This is in line with our finding that higher baseline PROMIS Physical Health score, representing better overall health, led to less postoperative opioid use. Lastly, mental health disorders are consistently cited among the risk factors for opioid use. In a population-based study to identify risk factors for developing prolonged opioid use following elective and trauma-related surgeries, Johnson et al ³ found that mental health disorders, specifically anxiety and depression, and tobacco or alcohol dependence or abuse were associated with prolonged opioid use. Furthermore, patients with anxiety and depression have an increased probability of filing opioid prescriptions and exhibiting extended opioid use after orthopedic surgery.^3,6 Paradoxically, our results showed a positive correlation between PROMIS Mental Health scores and OME consumption, meaning higher mental health function was associated with increased OME consumption, a finding that is in contrast with the available literature. This could be due to a mode effect for telephone interviewer-administration. It has previously been demonstrated that patients provide more positive score estimates with telephone administration than with self-administration. ³⁰

This study has several limitations. First, it relied on self-reported data while formal allergy and psychiatric testing were not performed. Additionally, given our desire to examine the relationship between PRAs and opioid use, we excluded patients with self-reported opioid allergy. Furthermore, the comparative groups were heterogeneous regarding baseline pain levels, procedures performed and type of anesthesia used, which may have impacted postoperative opioid use. We do not report on either long-term opioid use or patient functional outcomes to determine the clinical relevance of increasing opioid use with number of PRAs. Prior orthopedic literature has reported differences in functional outcomes between patients with and without allergies^10,11,13 Lastly, given the relatively small number of patients in our cohort with larger numbers of allergies, we were unable to report on this potentially unique population. Our overall sample size, however, was comparable to prior literature. ¹⁸

Conclusion

In conclusion, patients with PRAs tended to be women, have lower mental health function scores, and higher preoperative pain levels. The presence of PRAs did not result in significantly greater postoperative narcotic usage. However, increasing number of PRAs was significantly correlated with higher narcotic use, even in our cohort in which relatively small numbers of opioids were consumed postoperatively. While surgeons and surgical staff may not take an extensive psychiatric history, a list of allergies is always collected preoperatively and available for review. Thus, PRAs are accessible and may serve as a means of identifying patients who are at risk for postoperative opioid abuse. These results may have implications for postoperative pain management in this population. As surgeons are key prescribers of opioids, it is essential that they are aware of preoperative patient factors that are associated with increased opioid use. Further research in a prospective manner is warranted to corroborate these findings and better understand their impact on outcomes following hand surgery.