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A prospective observational study of persistent opioid use after complex foot and ankle surgery

Étude observationnelle prospective de la consommation persistante d’opioïdes après une chirurgie complexe du pied et de la cheville



The incidence of persistent postsurgical opioid use (PPOU) after complex foot and ankle surgery is unknown. We aimed to determine the incidence and characteristics of PPOU in opioid-naïve, occasional, and regular opioid users at baseline and at six weeks, three months, and six months postoperatively.


We conducted a prospective observational study in patients undergoing complex foot and ankle surgery over an 18-month period. Daily opioid consumption was recorded at the indicated intervals. Logistic regression models were fit to predict the risk of opioid use at these intervals. The Brief Pain Inventory (BPI) was used to record pain intensity and interference. Correlations were tested between opioid use and BPI interference parameters.


Eighty-two out of 139 consecutively approached patients were included in the final analysis. Six percent (98.3% confidence interval [CI], 2 to 20) of patients who were not using opioids preoperatively at baseline were using opioids daily at three and six months after surgery. Fifty percent (98.3% CI, 26 to 73) of patients who were regular opioid users preoperatively continued to use opioids daily six months after surgery. All associations between BPI interference parameters and opioid use were estimated to be positive.


The probability of using opioid analgesia six months after complex foot and ankle surgery was significantly higher in patients who used opioids preoperatively. Regular preoperative opioid use was associated with a greater risk of PPOU compared with occasional or “as required” opioid use prior to surgery.



L’incidence de consommation persistante d’opioïdes après une chirurgie (CPOC) après une chirurgie complexe du pied et de la cheville est inconnue. Notre objectif était de déterminer l’incidence et les caractéristiques de la CPOC chez les utilisateurs d’opioïdes naïfs, occasionnels et réguliers avant leur opération, puis à six semaines, trois mois et six mois après l’opération.


Nous avons réalisé une étude observationnelle prospective sur une période de 18 mois auprès de patients bénéficiant d’une chirurgie complexe du pied et de la cheville. La consommation quotidienne d’opioïdes a été enregistrée aux intervalles indiqués. Des modèles de régression logistique ont été utilisés pour prédire le risque de consommation d’opioïdes à ces intervalles. Le Questionnaire concis de la douleur (QCD - version française du Brief Pain Inventory, BPI) a été utilisé pour enregistrer l’intensité de la douleur et son interférence. Des corrélations ont été testées entre la consommation d’opioïdes et les paramètres d’interférence du QCD.


Quatre-vingt-deux des 139 patients approchés consécutivement ont été inclus dans notre analyse finale. Six pour cent (intervalle de confiance [IC] à 98,3 %, 2 à 20) des patients qui ne consommaient pas d’opioïdes avant l’opération utilisaient des opioïdes quotidiennement trois et six mois après la chirurgie. Cinquante pour cent (IC 98,3 %, 26 à 73) des patients qui étaient des consommateurs réguliers d’opioïdes avant l’opération ont continué à utiliser des opioïdes quotidiennement six mois après la chirurgie. Toutes les associations entre les paramètres d’interférence du QCD et la consommation d’opioïdes ont été estimées positives.


La probabilité d’avoir recours à une analgésie opioïde six mois après une chirurgie complexe du pied et de la cheville était significativement plus élevée chez les patients qui consommaient déjà des opioïdes avant leur opération. La consommation régulière d’opioïdes avant l’opération a été associée à un risque plus élevé de CPOC par rapport à l’utilisation occasionnelle ou « au besoin » d’opioïdes avant la chirurgie.

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  1. 1.

    STROBE. Strengthening the reporting of observational studies in epidemiology Available from URL: (accessed August 2021).


  1. 1.

    Schug SA, Bruce J. Risk stratification for the development of chronic postsurgical pain. Pain Rep 2017; DOI:

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Remerand F, Godfroid HB, Brilhault J, et al. Chronic pain 1 year after foot surgery: epidemiology and associated factors. Orthop Traumatol Surg Res 2014; 100: 767-73.

    CAS  Article  Google Scholar 

  3. 3.

    Stiegelmar C, Li Y, Beaupre LA, Pedersen ME, Dillane D, Funabashi M. Perioperative pain management and chronic postsurgical pain after elective foot and ankle surgery: a scoping review. Can J Anesth 2019; 66: 953-65.

    Article  Google Scholar 

  4. 4.

    Howard R, Waljee JF. Excessive opioid prescribing after surgery - a uniquely American problem. Ann Surg 2020; 272: 887-8.

    Article  Google Scholar 

  5. 5.

    Kaafarani HM, Han K, El Moheb M, et al. Opioids after surgery in the United States versus the rest of the world: the international patterns of opioid prescribing (iPOP) multicenter study. Ann Surg 2020; 272: 879-86.

    Article  Google Scholar 

  6. 6.

    Kent ML, Hurley RW, Oderda GM, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on persistent postoperative opioid use: definition, incidence, risk factors, and health care system initiatives. Anesth Analg 2019; 129: 543-52.

    Article  Google Scholar 

  7. 7.

    Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 2014; DOI:

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med 2012; 172: 425-30.

    Article  Google Scholar 

  9. 9.

    Cleeland CS. The Brief Pain Inventory User Guide 2009. Available from URL: (accessed August 2021).

  10. 10.

    Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singap 1994; 23: 129-38.

    CAS  PubMed  Google Scholar 

  11. 11.

    Brown LD, Cai TT, DasGupta A. Interval estimation for a binomial proportion. Statist Sci 2001; 16: 101-33.

    Article  Google Scholar 

  12. 12.

    Heinze G. A comparative investigation of methods for logistic regression with separated or nearly separated data. Stat Med 2006; 25: 4216-26.

    Article  Google Scholar 

  13. 13.

    Lawal OD, Gold J, Murthy A, et al. Rate and risk factors associated with prolonged opioid use after surgery: a systematic review and meta-analysis. JAMA Netw Open 2020; DOI:

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Mulligan RP, McCarthy KJ, Grear BJ, Richardson DR, Ishikawa SN, Murphy GA. Psychosocial risk factors for postoperative pain in ankle and hindfoot reconstruction. Foot Ankle Int 2016; 37: 1065-70.

    Article  Google Scholar 

  15. 15.

    Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg 2012; 115: 694-702.

    Article  Google Scholar 

  16. 16.

    Ladha KS, Neuman MD, Broms G, et al. Opioid prescribing after surgery in the United States, Canada, and Sweden. JAMA Netw Open 2019; DOI:

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Stamer UM, Ehrler M, Lehmann T, Meissner W, Fletcher D. Pain-related functional interference in patients with chronic neuropathic postsurgical pain: an analysis of registry data. Pain 2019; 160: 1856-65.

    Article  Google Scholar 

  18. 18.

    Katz J, Weinrib A, Fashler SR, et al. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res 2015; 8: 695-702.

    Article  Google Scholar 

  19. 19.

    Page MG, Kudrina I, Zomahoun HT, et al. A systematic review of the relative frequency and risk factors for prolonged opioid prescription following surgery and trauma among adults. Ann Surg 2020; 271: 845-54.

    Article  Google Scholar 

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Author contributions

Michelle Verrier, Shuang Niu, and Chris Douglas contributed to study design and data collection. Kimberly Kroetch contributed to statistical analysis. Karen Buro contributed to statistical analysis and writing the manuscript. James Green and Mary E. Pedersen, and Derek Dillane contributed to study design and writing the manuscript.



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This submission was handled by Dr. Stephan K.W. Schwarz, Editor-in-Chief, Canadian Journal of Anesthesia/ Journal canadien d’anesthésie.

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Correspondence to Derek Dillane MB BCh, BAO, FCARCSI.

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Verrier, M., Niu, S., Kroetch, K. et al. A prospective observational study of persistent opioid use after complex foot and ankle surgery. Can J Anesth/J Can Anesth (2021).

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  • Persistent postsurgical opioid use
  • Complex foot and ankle surgery
  • Brief pain inventory