Opioid Prescribing Patterns Associated With Nail Biopsies: A TriNetX Analysis

Nail biopsy is associated with moderate-to-severe postoperative pain 1, with non-opioids providing comparable analgesia to opioids 2. Since the rate and risk factors associated with opioid prescribing for nail biopsies are largely unknown, we conducted a retrospective cohort study using a national database. On November 10, 2025, the TriNetX research network was queried 2005–2025 for all patients with vs. without opioid prescription ≤ 3-days after nail biopsy. A secondary analysis analyzed prescriptions ≤ 3-days before and after biopsy to evaluate for potential standing opioid prescriptions. Demographics were analyzed. Cox regression calculated hazard ratios (HR) and 95% confidence intervals (CI) of opioid prescription ≤ 3-days after biopsy for the overall nail biopsy cohort, evaluating for covariate risk factors associated with prolonged opioid use 3 within the patient's history ≤ 3-years prior to biopsy. Overall, 12,511 patients underwent nail biopsy, with 1820 prescribed opioids (opioid prescription rate 14.5%). Opioid prescription rate ≤ 3-days before and after biopsy (15.2%) was similar, indicating minimal non-biopsy-related prescribing. The relatively high short-interval rate supports a temporal association with biopsy. Patients who underwent nail biopsy were, on average, 53.2 years, 61.4% female, and 66.4% White. Older age (HR = 0.989, 95% CI: 0.986–0.992), White race (0.685, 0.603–0.778), Black/African-American race (0.794, 0.680–0.927), and anxiety (0.817, 0.702–0.951) or chronic pain (0.827, 0.707–0.968) history were associated with lower hazard of post-biopsy opioid prescription, whereas prior antidepressant (1.142, 1.011–1.289) or opioid (1.374, 1.211–1.558) use, fibromyalgia (1.299, 1.037–1.629), and osteoarthritis (1.165, 1.023–1.326) were associated with greater hazard (Table 1). We found relatively high opioid prescription rates associated with nail biopsy, suggesting potential overuse given demonstrated efficacy of nonopioid analgesic regimens 2. For example, a prospective observational study of 20 patients undergoing nail biopsy reported mean pain scores peaking at 6–12-h post-procedure and decreasing by 0.4 points/day, with 90% of patients treated without opioids 1. Additionally, a randomized-controlled trial of 20 nail surgery patients found comparable pain scores ≤ 48-h post-procedure among patients treated with acetaminophen/ibuprofen and hydrocodone/acetaminophen (p > 0.05) 2. Additionally, we found that younger age, non-White and non-Black/African-American race, fibromyalgia, osteoarthritis, and prior opioid or antidepressant use were associated with greater likelihood of opioid prescription, whereas anxiety or chronic pain were associated with lower likelihood. These prescribing patterns may reflect differential pain reporting and prescriber bias. Similarly, in a retrospective study of 356,285 Mohs micrographic surgery (MMS) patients, 13.2% were prescribed opioids ≤ 14 days after MMS, with increased likelihood for non-White patients (1.31, 1.23–1.39) and those with chronic pain (1.21, 1.12–1.31), and decreased likelihood with opioid use disorder (0.75, 0.58–0.98) 4. These findings, taken together, highlight the need for standardized prescribing practices to balance postoperative analgesia with opioid stewardship. Limitations include potential miscoding, limited nail disease diagnostic codes, and inability to assess physician type, indication, anatomical location or nail biopsy technique, or distinguish standing from biopsy-specific prescriptions. Association does not imply causation. Analyzed time frames are estimates. In conclusion, current opioid prescribing associated with nail biopsy may exceed clinical necessity and may be influenced by demographics and comorbidities. We recommend routine use of non-opioid analgesics post-nail biopsy, reserving opioids for patients on an individualized basis after re-evaluation. Ms. Podolsky and Dr. Ricardo have no financial disclosures. Dr. Lipner has served as a consultant for Moberg Pharmaceuticals and BelleTorus Corporation. AI was not used in manuscript composition. This retrospective study is exempt from informed consent. The data reviewed is a secondary analysis of existing data, does not involve intervention or interaction with human subjects, and is de-identified per the de-identification standard defined in Section §164.514(a) of the HIPAA Privacy Rule. The process by which the data is de-identified is attested to through a formal determination by a qualified expert as defined in Section §164.514(b) (1) of the HIPAA Privacy Rule. This formal determination by a qualified expert refreshed in December 2020. The authors declare no conflicts of interest. The data that support the findings of this study are available from TriNetX. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of TriNetX.