Trauma/Critical Care Presented at the Academic Surgical Congress 2020| Volume 168, ISSUE 4, P684-689, October 2020

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Patterns and predictors of opioid prescribing and use after rib fractures



      Rib fractures are painful injuries that are treated with aggressive analgesia, which can include opioids. We sought to evaluate the patterns and predictors of opioid prescription and sustained use for rib fracture patients to identify opportunities for opiate reduction.


      We used TRICARE claims data (2006–2014) to identify adult (18–64 years) patients presenting to the emergency department with rib fracture(s) and isolated chest trauma. We used logistic regression and Cox proportional hazards model to identify factors associated with opioid prescription and duration of use.


      We identified 29,943 patients meeting inclusion criteria, and 2,542 (9%) patients were prescribed opioids. When prescribed, the median duration opioid use was 16 days (interquartile range 6–31) for opioid naïve patients, compared with 36 days (interquartile range 15–134) for those with prior opioid exposure. Increased number of ribs fractured (6+ fractures) (odds ratio 2.96 [95% confidence interval 2.23–3.94], P < .001) and prior opioid exposure (odds ratio 32.95 [29.36–36.99], P < .001) were significant predictors of initial opioid prescription. Patients with prior opioid exposure (hazard ratio 0.47 [0.43–0.52], P < .001) had lower likelihood of opioid discontinuation. Injury characteristics did not significantly predict discontinuation.


      Prior opioid exposure was the strongest predictor of sustained opioid use after rib fractures, while the severity of injury did not predict the duration of use.
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        • Ziegler D.W.
        • Agarwal N.N.
        The morbidity and mortality of rib fractures.
        J Trauma. 1994; 37: 975-979
        • Flagel B.T.
        • Luchette F.A.
        • Reed R.L.
        • et al.
        Half-a-dozen ribs: the breakpoint for mortality.
        Surgery. 2005; 138 (discussion 723–725): 717-725
        • Holcomb J.B.
        • McMullin N.R.
        • Kozar R.A.
        • Lygas M.H.
        • Moore F.A.
        Morbidity from rib fractures increases after age 45.
        J Am Coll Surg. 2003; 196: 549-555
        • Mackersie R.
        • Karagianes T.
        • Hoyt D.
        • Davis J.
        Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures.
        J Trauma. 1991; 31 (discussion 449–451): 443-449
        • Galvagno Jr., S.M.
        • Smith C.E.
        • Varon A.J.
        • et al.
        Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society.
        J Trauma Acute Care Surg. 2016; 81: 936-951
        • Kerr-Valentic M.A.
        • Arthur M.
        • Mullins R.J.
        • Pearson T.E.
        • Mayberry J.C.
        Rib fracture pain and disability: can we do better?.
        J Trauma. 2003; 54: 1058-1064
        • Fabricant L.
        • Ham B.
        • Mullins R.
        • Mayberry J.
        Prolonged pain and disability are common after rib fractures.
        Am J Surg. 2013; 205: 511-516
        • Gordy S.
        • Ham B.
        • Mullins R.
        • Mayberry J.
        The contribution of rib fractures to chronic pain and disability.
        Am J Surg. 2014; 207: 659-663
        • Kolodny A.
        • Courtwright D.T.
        • Hwang C.S.
        • et al.
        The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction.
        Annu Rev Public Health. 2015; 36: 559-574
        • Schoenfeld A.J.
        • Jiang W.
        • Chaudhary M.A.
        • Scully R.E.
        • Koehlmoos T.
        • Haider A.H.
        Sustained prescription opioid use among previously opioid- naïve patients insured through TRICARE (2006-2014).
        JAMA Surg. 2017; 152: 1175-1176
        • Chaudhary M.A.
        • Schoenfeld A.J.
        • Harlow A.F.
        • et al.
        Incidence and predictors of opioid prescription at discharge after traumatic injury.
        JAMA Surg. 2017; 152: 930-936
        • Scully R.E.
        • Schoenfeld A.J.
        • Jiang W.
        • et al.
        Defining optimal length of opioid pain medication prescription after common surgical procedures.
        JAMA Surg. 2018; 153: 37-43
        • Chaudhary M.A.
        • Bhulani N.
        • De Jager E.C.
        • et al.
        Development and validation of a bedside risk assessment for sustained prescription opioid use after surgery.
        JAMA Netw Open. 2019; 2e196673
        • Chaudhary M.A.
        • von Keudell A.
        • Bhulani N.
        • et al.
        Prior prescription opioid use and its influence on opioid requirements after orthopedic trauma.
        J Surg Res. 2019; 238: 29-34
        • Schoenfeld A.J.
        • Kaji A.H.
        • Haider A.H.
        Practical guide to surgical data sets: military health system Tricare encounter data.
        JAMA Surg. 2018; 153: 679-680
        • Gimbel R.W.
        • Pangaro L.
        • Barbour G.
        America’s “undiscovered” laboratory for health services research.
        Med Care. 2010; 48: 751-756
        • Schoenfeld A.J.
        • Jiang W.
        • Harris M.B.
        • et al.
        Association between race and postoperative outcomes in a universally insured population versus patients in the State of California.
        Ann Surg. 2017; 266: 267-273
        • Zogg C.K.
        • Jiang W.
        • Chaudhary M.A.
        • et al.
        Racial disparities in emergency general surgery: do differences in outcomes persist among universally insured military patients?.
        J Trauma Acute Care Surg. 2016; 80 (discussion 775–777): 764-775
        • US Drug Enforcement Administation
        Controlled substances by CSA schedule.
        • Feinberg A.E.
        • Chesney T.R.
        • Srikandarajah S.
        • Acuna S.A.
        • McLeod R.S.
        Best Practice in Surgery Group. Opioid use after discharge in postoperative patients.
        Ann Surg. 2018; 267: 1056-1062
        • Lyapustina T.
        • Rutkow L.
        • Chang H.Y.
        • et al.
        Effect of a “pill mill” law on opioid prescribing and utilization: the case of Texas.
        Drug Alcohol Depend. 2016; 159: 190-197
        • Soelberg C.D.
        • Brown Jr., R.E.
        • Du Vivier D.
        • Meyer J.E.
        • Ramachandran B.K.
        The US opioid crisis: current federal and state legal issues.
        Anesth Analg. 2017; 125: 1675-1681
      1. New Jersey Division of Consumer Affairs. Rule N.J.A.C 3:35-7.6 Limitations on prescribing, administering, or dispensing of controlled dangerous substances; special requirements for management of acute and chronic pain.
        • Todd S.R.
        • McNally M.M.
        • Holcomb J.B.
        • et al.
        A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients.
        Am J Surg. 2006; 192: 806-811
        • Dalton M.K.
        • Minarich M.J.
        • Twaddell K.J.
        • Hazelton J.P.
        • Fox N.M.
        The expedited discharge of patients with multiple traumatic rib fractures is cost-effective.
        Injury. 2019; 50: 109-112