Association Between High‐Risk Preexisting Substance Use and Increased Postoperative Opioid Dose Use Among Adolescents Undergoing Ambulatory Orthopedic Surgery

BACKGROUND: High-risk substance use is a public health concern among adolescents placing them at increased likelihood for opioid misuse and overdose. However, whether high-risk substance use is associated with increased postoperative opioid use remains poorly described. This study aimed to determine whether preoperative high-risk substance use is associated with increased postoperative opioid use in adolescents. METHODS: This longitudinal study included opioid-naive adolescents undergoing ambulatory orthopedic surgery. Preoperative high-risk substance use was stratified using the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD). Postoperative opioid dose use was recorded with an objective electronic medication adherence device. Postoperative pain was reported every 4 h using a smartphone diary. Multivariable regression analyses for cross-sectional data and multivariable mixed modeling for longitudinal data were performed. RESULTS: Participants (n 121) aged 15 years (mean; range 11-19) (49% females) had mostly knee, some shoulder and elbow surgery. Only 13/121 (10.7%) reported high substance use risk, none reported low risk, with the majority (89.3%) reporting no substance intake in the prior 12 months. Patients with high-risk preoperative substance use took twice the postoperative opioid doses compared to those with no use 12.2 (2.7) versus 5.6 (0.6) (p < 0.0001). Multivariate negative binomial regression analysis, controlling for sociodemographic and clinical factors, confirmed high-risk preoperative substance use was associated with increased postoperative opioid dose use (incidence rate ratio 1.96, 95% CI: 1.12-3.43, p = 0.018). Longitudinal analysis over 14 days revealed that while adolescents with high-risk substance use overall used more opioids for their pain, they were also less likely to vary their opioid use in response to lower levels of pain intensity as compared to adolescents without substance use. CONCLUSIONS: High-risk preoperative substance use was associated with increased postoperative opioid use in opioid-naïve adolescents following elective ambulatory orthopedic surgery. These findings, although limited by small sample size, highlight the need for presurgery substance use screening to guide personalized strategies, potentially reduce opioid use, improve pain management, and lower misuse risk.