Editor's choice| Volume 44, ISSUE 10, P829-839, October 2019

Effects of Baseline Opioid Medication Use on Patient-Reported Functional and Psychological Impairment Among Hand Clinic Patients

Published:August 30, 2019DOI:


      To test the null hypothesis that baseline opioid use is not associated with functional or psychological impairment among new hand surgery clinic patients, as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) instruments.


      New adult (≥ 18 years) patient visits to a tertiary academic orthopedic nonshoulder hand and upper extremity clinic between February 2014 and April 2018 were eligible. Collected outcomes include the question, “Are you currently taking narcotic pain medications?”, the PROMIS Upper Extremity (UE) computerized adaptive testing (CAT), abbreviated version of the Disorders of the Arm, Shoulder, and Hand (QuickDASH), PROMIS Physical Function (PF) CAT, PROMIS Pain Interference (PI) CAT, PROMIS Depression CAT, and PROMIS Anxiety CAT. Patients responding to the opioid question, plus the UE CAT or QuickDASH, were included. Bivariate and multivariable logistic regression modelling were used to assess factors associated with baseline scores.


      Of 5997 included patients, 1,046 (17.4%) reported baseline opioid use. Patients in the opioid group demonstrated significantly worse scores on all patient-reported outcomes, and a significantly greater proportion of patients with PROMIS Depression CAT scores exceeding 60 (associated with a clinical diagnosis of depression; 29.5% vs 15.5%). Lower functional scores were observed in the opioid group after controlling for age, sex, other activity-limiting comorbidities, and either depression (UE CAT –7.0; QuickDASH +18.1; and PF CAT –6.6 points), anxiety (UE CAT –6.3; QuickDASH +16.4; PF CAT –6.3), or PI (UE CAT –3.7; QuickDASH +9.5; and PF CAT –4.2 points). Pain interference was greater among opiate users when controlling for age, sex, other activity-limiting comorbidities, and baseline function or psychological status: PI was 2.5, 5.0, or 4.3 points greater when controlling for the PROMIS UE CAT, Depression CAT, or Anxiety CAT.


      New patients presenting to a hand surgery clinic who endorse use of opioid medications at baseline report significantly decreased physical function, increased psychological burden, and greater levels of pain interference than nonusers.

      Type of study/level of evidence

      Diagnostic III.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Trasolini N.A.
        • McKnight B.M.
        • Dorr L.D.
        The opioid crisis and the orthopedic surgeon.
        J Arthroplasty. 2018; 33: 3379-3382.e1
        • Soffin E.M.
        • Waldman S.A.
        • Stack R.J.
        • Liguori G.A.
        An evidence-based approach to the prescription opioid epidemic in orthopedic surgery.
        Anesth Analg. 2017; 125: 1704-1713
        • Bicket M.C.
        • Long J.J.
        • Pronovost P.J.
        • Alexander G.C.
        • Wu C.L.
        Prescription opioid analgesics commonly unused after surgery: a systematic review.
        JAMA Surg. 2017; 152: 1066-1071
        • Stanek J.J.
        • Renslow M.A.
        • Kalliainen L.K.
        The effect of an educational program on opioid prescription patterns in hand surgery: a quality improvement program.
        J Hand Surg Am. 2015; 40: 341-346
        • Johnson S.P.
        • Chung K.C.
        • Zhong L.
        • et al.
        Risk of prolonged opioid use among opioid-naive patients following common hand surgery procedures.
        J Hand Surg Am. 2016; 41: 947-957.e3
        • Morris B.J.
        • Mir H.R.
        The opioid epidemic: impact on orthopaedic surgery.
        J Am Acad Orthop Surg. 2015; 23: 267-271
        • Kelley B.P.
        • Shauver M.J.
        • Chung K.C.
        Management of acute postoperative pain in hand surgery: a systematic review.
        J Hand Surg Am. 2015; 40: 1610-1619.e1
        • Rodgers J.
        • Cunningham K.
        • Fitzgerald K.
        • Finnerty E.
        Opioid consumption following outpatient upper extremity surgery.
        J Hand Surg Am. 2012; 37: 645-650
        • Alexander G.C.
        • Kruszewski S.P.
        • Webster D.W.
        Rethinking opioid prescribing to protect patient safety and public health.
        JAMA. 2012; 308: 1865-1866
        • Okie S.
        A flood of opioids, a rising tide of deaths.
        N Engl J Med. 2010; 363: 1981-1985
        • Brunton L.M.
        • Laporte D.M.
        Use of opioids in hand surgery.
        J Hand Surg Am. 2009; 34: 1551-1554
        • Manchikanti L.
        • Singh A.
        Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids.
        Pain Physician. 2008; 11: S63-S88
        • Kuehn B.M.
        Opioid prescriptions soar: increase in legitimate use as well as abuse.
        JAMA. 2007; 297: 249-251
        • Mularski R.A.
        • White-Chu F.
        • Overbay D.
        • Miller L.
        • Asch S.M.
        • Ganzini L.
        Measuring pain as the 5th vital sign does not improve quality of pain management.
        J Gen Intern Med. 2006; 21: 607-612
        • Stepan J.G.
        • London D.A.
        • Osei D.A.
        • Boyer M.I.
        • Dardas A.Z.
        • Calfee R.P.
        Perioperative celecoxib and postoperative opioid use in hand surgery: a prospective cohort study.
        J Hand Surg Am. 2018; 43: 346-353
        • Stepan J.G.
        • Sacks H.A.
        • Lovecchio F.C.
        • et al.
        Opioid prescriber education and guidelines for ambulatory upper-extremity surgery: evaluation of an institutional protocol.
        J Hand Surg Am. 2019; 44: 129-136
        • Labrum IV, J.T.
        • Ilyas A.M.
        Perioperative pain control in upper extremity surgery: prescribing patterns, recent developments, and opioid-sparing treatment strategies.
        Hand (N Y). 2019; 14: 439-444
        • Dwyer C.L.
        • Soong M.
        • Hunter A.
        • Dashe J.
        • Tolo E.
        • Kasparyan N.G.
        Prospective evaluation of an opioid reduction protocol in hand surgery.
        J Hand Surg Am. 2018; 43: 516-522.e1
        • Lovecchio F.
        • Derman P.
        • Stepan J.
        • et al.
        Support for safer opioid prescribing practices: a catalog of published use after orthopaedic surgery.
        J Bone Joint Surg Am. 2017; 99: 1945-1955
        • Alter T.H.
        • Ilyas A.M.
        A prospective randomized study analyzing preoperative opioid counseling in pain management after carpal tunnel release surgery.
        J Hand Surg Am. 2017; 42: 810-815
        • Jain N.
        • Brock J.L.
        • Phillips F.M.
        • Weaver T.
        • Khan S.N.
        Chronic preoperative opioid use is a risk factor for increased complications, resource use, and costs after cervical fusion.
        Spine J. 2019; 32: 113-119
        • Nota S.
        • Spit S.
        • Voskuyl T.
        • Bot A.
        • Hageman M.
        • Ring D.
        Opioid use, satisfaction, and pain intensity after orthopedic surgery.
        Psychosomatics. 2015; 56: 479-485
        • Menendez M.E.
        • Ring D.
        • Bateman B.T.
        Preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery.
        Clin Orthop Relat Res. 2015; 473: 2402-2412
        • Lee D.
        • Armaghani S.
        • Archer K.R.
        • et al.
        Preoperative opioid use as a predictor of adverse postoperative self-reported outcomes in patients undergoing spine surgery.
        J Bone Joint Surg Am. 2014; 96: e89
        • Helmerhorst G.T.
        • Vranceanu A.M.
        • Vrahas M.
        • Smith M.
        • Ring D.
        Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma.
        J Bone Joint Surg Am. 2014; 96: 495-499
        • Holman J.E.
        • Stoddard G.J.
        • Higgins T.F.
        Rates of prescription opiate use before and after injury in patients with orthopaedic trauma and the risk factors for prolonged opiate use.
        J Bone Joint Surg Am. 2013; 95: 1075-1080
        • Zywiel M.G.
        • Stroh D.A.
        • Lee S.Y.
        • Bonutti P.M.
        • Mont M.A.
        Chronic opioid use prior to total knee arthroplasty.
        J Bone Joint Surg Am. 2011; 93: 1988-1993
        • Clover K.
        • Lambert S.D.
        • Oldmeadow C.
        • et al.
        PROMIS depression measures perform similarly to legacy measures relative to a structured diagnostic interview for depression in cancer patients.
        Qual Life Res. 2018; 27: 1357-1367
        • Beleckas C.M.
        • Prather H.
        • Guattery J.
        • Wright M.
        • Kelly M.
        • Calfee R.P.
        Anxiety in the orthopedic patient: using PROMIS to assess mental health.
        Qual Life Res. 2018; 27: 2275-2282
        • Schalet B.D.
        • Cook K.F.
        • Choi S.W.
        • Cella D.
        Establishing a common metric for self-reported anxiety: linking the MASQ, PANAS, and GAD-7 to PROMIS Anxiety.
        J Anxiety Disord. 2014; 28: 88-96
      1. Prosetta stone: appendix table 34: Raw score to t-score conversion table (irt fixed parameter calibration linking) for GAD-7 to PROMIS Anxiety (toolbox study). 2018.
        (Available from:)
        • Peters B.
        • Izadpanah A.
        • Islur A.
        Analgesic consumption following outpatient carpal tunnel release.
        J Hand Surg Am. 2018; 43: 189.e5
        • Gauger E.M.
        • Gauger E.J.
        • Desai M.J.
        • Lee D.H.
        Opioid use after upper extremity surgery.
        J Hand Surg Am. 2018; 43: 470-479
        • Miller A.
        • Kim N.
        • Ilyas A.M.
        Prospective evaluation of opioid consumption following hand surgery performed wide awake versus with sedation.
        Hand (N Y). 2017; 12: 606-609
        • Sorensen A.A.
        • Howard D.
        • Tan W.H.
        • Ketchersid J.
        • Calfee R.P.
        Minimal clinically important differences of 3 patient-rated outcomes instruments.
        J Hand Surg Am. 2013; 38: 641-649
        • Polson K.
        • Reid D.
        • McNair P.J.
        • Larmer P.
        Responsiveness, minimal importance difference and minimal detectable change scores of the shortened disability arm shoulder hand (QuickDASH) questionnaire.
        Man Ther. 2010; 15: 404-407
        • Franchignoni F.
        • Vercelli S.
        • Giordano A.
        • Sartorio F.
        • Bravini E.
        • Ferriero G.
        Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH).
        J Orthop Sports Phys Ther. 2014; 44: 30-39
        • Mintken P.E.
        • Glynn P.
        • Cleland J.A.
        Psychometric properties of the shortened disabilities of the arm, shoulder, and hand questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain.
        J Shoulder Elbow Surg. 2009; 18: 920-926
        • Sandvall B.
        • Okoroafor U.C.
        • Gerull W.
        • Guattery J.
        • Calfee R.P.
        Minimal clinically important difference for PROMIS physical function in patients with distal radius fractures.
        J Hand Surg Am. 2019; 44: 454-459.e1
        • Kazmers N.H.
        • Hung M.
        • Bounsanga J.
        • Voss M.W.
        • Howenstein A.
        • Tyser A.R.
        Minimal clinically important difference after carpal tunnel release using the PROMIS platform [published online ahead of print May 6, 2019]. J Hand Surg Am.
        • Ho B.
        • Houck J.R.
        • Flemister A.S.
        • et al.
        Preoperative PROMIS scores predict postoperative success in foot and ankle patients.
        Foot Ankle Int. 2016; 37: 911-918
        • Yost K.J.
        • Eton D.T.
        • Garcia S.F.
        • Cella D.
        Minimally important differences were estimated for six patient-reported outcomes measurement information system cancer scales in advanced-stage cancer patients.
        J Clin Epidemiol. 2011; 64: 507-516
        • Eton D.T.
        • Cella D.
        • Yost K.J.
        • et al.
        A combination of distribution- and anchor-based approaches determined minimally important differences (MIDS) for four endpoints in a breast cancer scale.
        J Clin Epidemiol. 2004; 57: 898-910
        • Amtmann D.
        • Kim J.
        • Chung H.
        • Askew R.L.
        • Park R.
        • Cook K.F.
        Minimally important differences for Patient Reported Outcomes Measurement Information System pain interference for individuals with back pain.
        J Pain Res. 2016; 9: 251-255
        • Chen C.X.
        • Kroenke K.
        • Stump T.E.
        • et al.
        Estimating minimally important differences for the PROMIS pain interference scales: results from 3 randomized clinical trials.
        Pain. 2018; 159: 775-782
      2. Healthmeasures—interpret scores: PROMIS. Northwestern University, 2019 (Available from:)
        • Ayers D.C.
        • Franklin P.D.
        • Ring D.C.
        The role of emotional health in functional outcomes after orthopaedic surgery: extending the biopsychosocial model to orthopaedics: AOA critical issues.
        J Bone Joint Surg Am. 2013; 95: e165
        • Kazmers N.H.
        • Hung M.
        • Rane A.A.
        • Bounsanga J.
        • Weng C.
        • Tyser A.R.
        Association of physical function, anxiety, and pain interference in nonshoulder upper extremity patients using the PROMIS platform.
        J Hand Surg Am. 2017; 42: 781-787
        • St John M.J.
        • Mitten D.
        • Hammert W.C.
        Efficacy of PROMIS pain interference and Likert pain scores to assess physical function.
        J Hand Surg Am. 2017; 42: 705-710
        • Vranceanu A.M.
        • Bachoura A.
        • Weening A.
        • Vrahas M.
        • Smith R.M.
        • Ring D.
        Psychological factors predict disability and pain intensity after skeletal trauma.
        J Bone Joint Surg Am. 2014; 96: e20
        • Vranceanu A.M.
        • Jupiter J.B.
        • Mudgal C.S.
        • Ring D.
        Predictors of pain intensity and disability after minor hand surgery.
        J Hand Surg Am. 2010; 35: 956-960
        • Vranceanu A.M.
        • Ring D.
        Value of psychological evaluation of the hand surgical patient.
        J Hand Surg Am. 2008; 33: 985-987
        • Engel G.L.
        The need for a new medical model: a challenge for biomedicine.
        Science. 1977; 196: 129-136
        • Oflazoglu K.
        • Mellema J.J.
        • Menendez M.E.
        • Mudgal C.S.
        • Ring D.
        • Chen N.C.
        Prevalence of and factors associated with major depression in patients with upper extremity conditions.
        J Hand Surg Am. 2016; 41 (e1–7): 263-269
        • Rivat C.
        • Ballantyne J.
        The dark side of opioids in pain management: basic science explains clinical observation.
        Pain Rep. 2016; 1: e570
        • Angst M.S.
        • Clark J.D.
        Opioid-induced hyperalgesia: a qualitative systematic review.
        Anesthesiology. 2006; 104: 570-587
        • Cozowicz C.
        • Olson A.
        • Poeran J.
        • et al.
        Opioid prescription levels and postoperative outcomes in orthopedic surgery.
        Pain. 2017; 158: 2422-2430
        • Hwang R.W.
        • Ring D.
        Pain and disability related to osteoarthrosis of the trapeziometacarpal joint.
        J Hand Microsurg. 2011; 3: 63-65
        • Hoffler 2nd, C.E.
        • Matzon J.L.
        • Lutsky K.F.
        • Kim N.
        • Beredjiklian P.K.
        Radiographic stage does not correlate with symptom severity in thumb basilar joint osteoarthritis.
        J Am Acad Orthop Surg. 2015; 23: 778-782
        • Tulipan J.E.
        • Lutsky K.F.
        • Maltenfort M.G.
        • Freedman M.K.
        • Beredjiklian P.K.
        Patient-reported disability measures do not correlate with electrodiagnostic severity in carpal tunnel syndrome.
        Plast Reconstr Surg Glob Open. 2017; 5: e1440
        • Kim N.
        • Matzon J.L.
        • Abboudi J.
        • et al.
        A prospective evaluation of opioid utilization after upper-extremity surgical procedures: identifying consumption patterns and determining prescribing guidelines.
        J Bone Joint Surg Am. 2016; 98: e89
        • Lewis E.T.
        • Cucciare M.A.
        • Trafton J.A.
        What do patients do with unused opioid medications?.
        Clin J Pain. 2014; 30: 654-662