Trends in Utilization of Multimodal Pain Management Following Pilon Fracture Open Reduction and Internal Fixation.

Abstract

To evaluate trends in pain medication prescriptions following pilon fracture open reduction and internal fixation (ORIF) in the context of recent initiatives to reduce opioid use and promote multimodal pain management. Design: Retrospective database study. US national administrative dataset (PearlDiver M170Ortho database). Included were patients undergoing pilon fracture (AO-OTA 43A/B/C) ORIF from 2010-2021 without history of pre-injury narcotic use, polytrauma, substance abuse, or neoplasm. This study captured prescriptions for pain medications within 90 days postoperatively after definitive pilon fracture fixation, categorized by drug category. Annual prescriptions and morphine milligram equivalents (MMEs) per 1,000 surgeries were trended over the study interval. Timing of opioid prescriptions postoperatively was determined. Multivariable analysis was performed to determine factors independently associated with opioid prescriptions. Included were 13,108 pilon fracture ORIF patients of which the average age was 50 years (range 18-84 year, (49.9%) female). Discretely billed outpatient opioid prescriptions decreased from 434.1 per 1,000 surgeries in 2010 to 165.7 in 2021 (-61.8%). Prescriptions of other pain management drugs on aggregate decreased less drastically from 276.6 in 2010 to 195.3 in 2021 (-29.4%). The proportion of all analgesics prescribed postoperatively that were opioids decreased from 60.3% in 2010 to 45.9% in 2021. Among patients who received opioids within 90-days postoperatively, MMEs prescribed per 1,000 pilon fracture ORIF surgeries decreased from 589,486 in 2010 to 59,795 in 2021 (-91.3%). 97% of opioids were prescribed in the first two weeks postoperatively. Predictors of postoperative opioid prescriptions by multivariate analysis included younger age (OR 1.29 per decade decrease), male sex (OR 1.54), lower ECI (OR 1.28) (p<0.0001 for all). Patients who had repair of tibia and fibula fractures did not have greater odds of postoperative opioid prescriptions than those who had repair of the tibia alone. Opioid prescriptions following pilon fracture ORIF decreased substantially from 2010 to 2021. Prescriptions for non-opioid analgesics also decreased but to a lesser extent. Younger age, male sex, and lower comorbidity burden were associated with higher post-operative opioid prescribing. III.