Cultural Nuance in Orthopedic Foreign Aid: Differences in Patient Concerns

Positive Association between Peri-Surgical Opioid Exposure and Post-Discharge Opioid-Related Outcomes

Background: Multiple studies have investigated the epidemic of persistent opioid use as a common postsurgical complication. However, there exists a knowledge gap in the association between the level of opioid exposure in the peri-surgical setting and post-discharge adverse outcomes to patients and healthcare settings. We analyzed the association between peri-surgical opioid exposure use and post-discharge outcomes, including persistent postsurgical opioid prescription, opioid-related symptoms (ORS), and healthcare resource utilization (HCRU). Methods: A retrospective cohort study included patients undergoing cesarean delivery, hysterectomy, spine surgery, total hip arthroplasty, or total knee arthroplasty in an academic healthcare system between January 2015 and June 2018. Peri-surgical opioid exposure was converted into morphine milligram equivalents (MME), then grouped into two categories: high (>median MME of each surgery cohort) or low (≤median MME of each surgery cohort) MME groups. The rates of persistent opioid use 30 and 90 days after discharge were compared using logistic regression. Secondary outcomes, including ORS and HCRU during the 180-day follow-up, were descriptively compared between the high and low MME groups. Results: The odds ratios (95% CI) of high vs. low MME for persistent opioid use after 30 and 90 days of discharge were 1.38 (1.24−1.54) and 1.41 (1.24−1.61), respectively. The proportion of patients with one or more ORS diagnoses was greater among the high-MME group than the low-MME group (27.2% vs. 21.2%, p < 0.01). High vs. low MME was positively associated with the rate of inpatient admission, emergency department admissions, and outpatient visits. Conclusions: Greater peri-surgical opioid exposure correlates with a statistically and clinically significant increase in post-discharge adverse opioid-related outcomes. The study findings warrant intensive monitoring for patients receiving greater peri-surgical opioid exposure.

Implementation of Procedure-Specific Opioid Guidelines: A Readily Employable Strategy to Improve Consistency and Decrease Excessive Prescribing Following Orthopaedic Surgery

Background:

Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines.

Methods:

This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME.

Results:

In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of <80 years (OR = 2.0 to 2.4; p < 0.001) and males (OR = 1.2; p = 0.025) were also shown to have higher odds of exceeding guideline maximums.

Conclusions:

Procedure-specific guidelines are capable of substantially decreasing opioid prescription amounts and variability. Furthermore, the absence of change in refill rates suggests that pain control remains similar to pre-guideline prescribing practices. Evidence-based guidelines are a readily employable solution that can drive rapid change in practice and enhance the ability of orthopaedic surgeons to provide responsible pain management.

The 2018 Chitranjan S. Ranawat, MD Award: Developing and Implementing a Novel Institutional Guideline Strategy Reduced Postoperative Opioid Prescribing After TKA and THA

BACKGROUND

Opioid prescription management is challenging for orthopaedic surgeons, and we lack evidence-based guidelines for responsible opioid prescribing. Our institution recently developed opioid prescription guidelines for patients undergoing several common orthopaedic procedures including TKA and THA in an effort to reduce and standardize prescribing patterns.

QUESTIONS/PURPOSES

(1) How do opioid prescriptions at discharge and 30-day refill rates change in opioid-naïve patients undergoing primary TKA and THA before and after implementation of a novel prescribing guideline strategy? (2) What patient, surgical, and in-hospital factors influence opioid prescription quantity and refill rate?

METHODS

New institutional guidelines for patients undergoing TKA and THA recommend a maximum postoperative prescription of 400 oral morphine equivalents (OME), comparable to 50 tablets of 5 mg oxycodone or 80 tablets of 50 mg tramadol. All opioid-naïve patients, defined as those who did not take any opioids within 90 days preceding surgery, undergoing primary TKA and THA at a single tertiary care institution were evaluated from program initiation on August 1, 2017, through December 31, 2017, as the postguideline era cohort. This group (n = 751 patients) was compared with all opioid-naïve patients undergoing TKA and THA from 2016 at the same institution (n = 1822 patients). Some providers were early adopters of the guidelines as they were being developed, which is why January to July 2017 was not evaluated. Patients in the preguideline and postguideline eras were not different in terms of age, sex, race, body mass index, education level, employment status, psychiatric illness, marital status, smoking history, outpatient use of benzodiazepines or gabapentinoids, or diagnoses of diabetes mellitus, peripheral neuropathy, or cancer. The primary outcome assessed was adherence to the new guidelines with a secondary outcome of opioid medication refills ordered within 30 days from any provider. Multivariable logistic regression analyses were performed with outcomes of guideline compliance and refills and adjusted for demographic, surgical, and patient care factors. Patients were followed for 30 days after surgery and no patients were lost to followup.

RESULTS

Median opioid prescription and range of prescriptions decreased in the postguideline era compared with the preguideline era (750 OME, interquartile range [IQR] 575-900 OME versus 388 OME, IQR 350-389; difference of medians = 362 OME; p < 0.001). There was no difference among patients undergoing TKA before and after guideline implementation in terms of the 30-day refill rate (35% [349 of 1011] versus 35% [141 of 399]; p = 0.77); this relationship was similar among patient undergoing THA (16% [129 of 811] versus 17% [61 of 352]; p = 0.55). After controlling for relevant patient-level factors, we found that implementation of an institutional guideline was the strongest factor associated with a prescription of ≤ 400 OME (adjusted odds ratio, 36; 95% confidence interval, 25-52; p < 0.001); although a number of patient-level factors also were associated with prescription quantity, the effect sizes were much smaller.

CONCLUSIONS

This study provides a proof of concept that institutional guidelines to reduce postoperative opioid prescribing can improve aftercare in patients undergoing arthroplasty in a short period of time. The current report evaluates our experience with the first 5 months of this program; therefore, longer term data will be mandatory to determine longitudinal guideline adherence and whether the cutoffs established by this pilot initiative require further refinement for individual procedures.

LEVEL OF EVIDENCE

Level II, therapeutic study.