Development of an Institutional Opioid Prescriber Education Program and Opioid-Prescribing Guidelines: Impact on Prescribing Practices

Managing an epidemic within a pandemic: orthopedic opioid prescribing trends during COVID-19

INTRODUCTION

In response to the opioid epidemic, a multitude of policy and clinical-guideline based interventions were launched to combat physician overprescribing. However, the sudden rise of the Covid-19 pandemic disrupted all aspects of healthcare delivery. The purpose of this study was to evaluate how opioid prescribing patterns changed during the Covid-19 pandemic within a large multispecialty orthopedic practice.

MATERIALS AND METHODS

A retrospective review of 1,048,559 patient encounters from January 1, 2015 to December 31, 2022 at a single orthopedic practice was performed. Primary outcomes were the percent of encounters with opioids prescribed and total morphine milligram equivalents (MMEs) per opioid prescription. Differences in outcomes were assessed by calendar year. Encounters were then divided into two groups: pre-Covid (1/1/2019-2/29/2020) and Covid (3/1/2020-12/31/2022). Univariate analyses were used to evaluate differences in diagnoses and outcomes between periods. Multivariate analysis was performed to assess changes in outcomes during Covid after controlling for differences in diagnoses. Statistical significance was assessed at p < 0.05.

RESULTS

The percentage of encounters with opioids prescribed decreased from a high of 4.0% in 2015 to a low of 1.6% in 2021 and 2022 (p < 0.001). MMEs per prescription decreased from 283.6 ± 213.2 in 2015 to a low of 138.6 ± 100.4 in 2019 (p < 0.001). After adjusting for diagnoses, no significant differences in either opioid prescribing rates (post-COVID OR = 0.997, p = 0.893) or MMEs (post-COVID β = 2.726, p = 0.206) were observed between the pre- and post-COVID periods.

CONCLUSION

During the Covid-19 pandemic opioid prescribing levels remained below historical averages. While continued efforts are needed to minimize opioid overprescribing, it appears that the significant progress made toward this goal was not lost during the pandemic era.

Postoperative Opioid Usage and Disposal Strategies After Arthroscopic Procedures in a Young Cohort: A Prospective Observational Study

Background

Although several studies have noted that patients are routinely overprescribed opioids, few have reported usage after arthroscopic surgery.

Purpose

To determine opioid consumption and allocation for unused opioids after common arthroscopic surgeries.

Study Design

Case series; Level of evidence, 4.

Methods

Patients between the ages of 15 and 40 years who were scheduled to undergo anterior cruciate ligament reconstruction (ACLR), labral repair of the hip or shoulder, meniscectomy, or meniscal repair were prospectively enrolled. Patients were prescribed either 5 mg hydrocodone-325 mg acetaminophen or 5 mg oxycodone-325 mg acetaminophen based on surgeon preference. Patients completed a daily opioid usage survey during the 2-week postoperative period. In addition, patients completed a survey on postoperative day 21 inquiring about continued opioid use and medication disposal, if applicable. Opioid medication consumption was converted to morphine milligram equivalents (MMEs).

Results

Of the 200 patients who were enrolled in the study, 176 patients had sufficient follow-up after undergoing 85 (48%) ACLR, 26 (14.8%) hip labral repair, 34 (19.3%) shoulder labral repair, 18 (10.2%) meniscectomy, and 13 (7.4%) meniscal repair procedures. Mean age was 26.1 years (SD, 7.38); surgeons prescribed a mean of 26.6 pills whereas patients reported consuming a mean of 15.5 pills. The mean MME consumption in the 14 days after each procedure was calculated: ACLR (95.7; 44% of prescription), hip labral repair (84.8; 37%), shoulder labral repair (57.2; 35%), meniscectomy (18.4; 27%), and meniscal repair (32.1; 42%). This corresponded to approximately 39% of the total opioid prescription being utilized across all procedures. Mean MME consumption was greatest on postoperative day 1 in hip, shoulder, and meniscal procedures and on postoperative day 2 in ACLR. Only 7.04% of patients reported continued opioid use in the third postoperative week. Patients had a mean of 11 unused pills or 77.7 MMEs remaining. Of the patients with remaining medication, 24.7% intended to keep their medication for future use.

Conclusion

The results of our study indicate that patients who undergo the aforementioned arthroscopic procedures consume <75 MMEs in the 2-week postoperative period, translating into a mean of 10 to 15 pills consumed. Approximately 60% of total opioids prescribed went unused, and one-fourth of patients intended to keep their remaining medication for future usage. We have provided general prescribing guidelines and recommend that surgeons carefully consider customizing their opioid prescriptions on the basis of procedure site to balance optimal postoperative analgesia with avoidance of dissemination of excess opioids.

Hospital-Wide Adherence to Postsurgical Opioid Prescribing Guidelines: A Retrospective Cohort Study

INTRODUCTION

Lowering opioid prescription doses and quantity decreases the risk of chronic opioid usage. A tool was inserted into the brief operative note for the surgeon to assess the severity of pain associated with the procedure. We studied surgeon adherence to current opioid-prescribing recommendations.

METHODS

Retrospective cohort study with 5486 patients were included in the study population. Each patient's prescription was scored yes or no for adherence on total morphine milligram equivalents (MMEs) and days prescribed with the selection in the brief operative note. The entire study population was tested for an increase from the null-hypothesis "benchmark" value of 75% using a one-sided exact binomial test of a single proportion with P < 0.05. This procedure was repeated for subgroups, with P < 0.01.

RESULTS

Adherence to guidelines was higher than the 75% benchmark for "total MMEs prescribed" (79.5%; P < 0.001), but lower for "number of days prescribed" (63.5%; P > 0.999). Surgeries with severe predicted pain showed the highest adherence toward total MMEs prescribed at 87.1%, followed by moderate (80.5%) and mild (74.5%). Severe cases also showed the highest adherence in number of days prescribed (92.4%). Adherence to total MMEs prescribed was highest among attending physicians (88.1%) and lowest among residents/fellows (76.6%).

CONCLUSIONS

Adherence to current guidelines was 79.5% for MMEs prescribed but only 63.5% for days prescribed. Compliance with guidelines was better for severe procedures than mild or moderate. Differences were seen across surgical departments. While an improvement from previous reports, further improvement is needed to reduce the number of days of opioids prescribed and increase compliance with recommended guidelines.

Impact of Timing of Targeted Muscle Reinnervation on Pain and Opioid Intake Following Major Limb Amputation

BACKGROUND

Targeted muscle reinnervation (TMR) has been shown to play an important role in managing neuromas. However, the impact of the timing of TMR on pain visual analogue scale (VAS) scores or patient opioid use has not been thoroughly explored. We hypothesized that TMR performed acutely would lead to lower VAS scores and decreased opioid intake.

METHODS

Prospectively collected data from an amputation registry at a single institution were utilized to identify patients who underwent TMR. Acute TMR was defined as TMR performed within 1 month of the major limb amputation. Primary outcomes included VAS pain scores and patient-reported opioid consumption.

RESULTS

In all, 25 patients (26 limbs) were identified in the acute group, and 18 patients (18 limbs) were identified in the delayed group. At intermediate follow-up (between 4 and 8 months postoperatively) and at final follow-up, the average pain VAS score in the delayed TMR group was significantly higher than that in the acute group (5.2 vs. 1.9 at intermediate P = .01 and 6.2 vs. 1.9 at final P = .002). In all, 84% of the amputees overall were not consuming opioid medications at the time of final follow-up (79% acute, 88% delayed, P = .72). There were no statistically significant differences in opioid consumption between the acute and delayed group at intermediate follow-up (P = .35) or at final follow-up (P = .68).

CONCLUSIONS

TMR is an effective procedure to reduce pain following major limb amputation. Patients with TMR performed acutely had significantly lower VAS pain scores at both intermediate and final follow-up than patients with TMR performed in a delayed setting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

An Institutional Curriculum for Opioid Prescribing Education: Outcomes From 2017 to 2022

INTRODUCTION

Prescription opioids, including those prescribed after surgery, have greatly contributed to the US opioid epidemic. Educating opioid prescribers is a crucial component of ensuring the safe use of opioids among surgical patients.

METHODS

An annual opioid prescribing education curriculum was implemented among new surgical prescribers at our institution between 2017 and 2022. The curriculum includes a single 75-min session which is comprised of several components: pain medications (dosing, indications, and contraindications); patients at high risk for uncontrolled pain and/or opioid misuse or abuse; patient monitoring and care plans; and state and federal regulations. Participants were asked to complete an opioid knowledge assessment before and after the didactic session.

RESULTS

Presession and postsession assessments were completed by 197 (89.6%) prescribers. Across the five studied years, the median presession score was 54.5%. This increased to 63.6% after completion of the curriculum, representing a median relative knowledge increase of 18.2%. The median relative improvement was greatest for preinterns and interns (18.2% for both groups); smaller improvements were observed for postgraduate year 2-5 residents (9.1%) and advanced practice providers (9.1%). On a scale of 1 to 10 (with 5 being comfortable), median (interquartile range) self-reported comfort in prescribing opioids increased from 3 (2-5) before education to 5 (4-6) after education (P < 0.001).

CONCLUSIONS

Each year, the curriculum substantially improved provider knowledge of and comfort in opioid prescribing. Despite increased national awareness of the opioid epidemic and increasing institutional initiatives to improve opioid prescribing practices, there was a sustained knowledge and comfort gap among new surgical prescribers. The observed effects of our opioid education curriculum highlight the value of a simple and efficient educational initiative.

The Impact of Florida Law HB21 on Opioid Prescribing Patterns After Outpatient Hand Surgery

BACKGROUND

The purpose of this study is to evaluate the effects of Florida lae House Bill 21 (HB21) on opioid prescribing patterns by a single orthopedic hand surgeon after outpatient hand and upper extremity surgery.

METHODS

The following variables were evaluated with retrospective chart review before and after implementation of HB21: type of opioid, number of pills, morphine milligram equivalents (MMEs), emergency department visits, and readmissions. In addition, the Florida Prescription Drug Monitoring Program (E-FORCSE [Electronic-Florida Online Reporting of Controlled Substance Evaluation]) was queried to determine the number of pills and MMEs prescribed and sold for the latter cohort. Student t tests, Fisher exact tests, and binary logistic regression were used for statistical analysis. P < .05 was considered significant.

RESULTS

We reviewed 231 consecutive patients who underwent hand or upper extremity surgery from July 2017 to July 2018 and 207 consecutive patients from January 2020 to January 2021. The average age was significantly different between the cohorts (48.41 vs 44.98 years, P = .025); however, there were no significant differences across other demographic variables. After controlling for age, the average number of pills prescribed per patient decreased significantly after HB21 (25.11 vs 21.6 pills, P < .001). The number of MMEs prescribed per patient decreased as well, but the decrease was not statistically significant (167.8 vs 154.1 MMEs, P = .054). There was an association between preoperative opioid prescriptions filled and prolonged opioid use (odds ratio 6.438, P = .003).

CONCLUSION

Florida law HB21 resulted in significantly fewer pills prescribed per patient, suggesting that legislation likely changed prescriber behavior and/or patient demand regarding postoperative opioid prescriptions after outpatient hand and upper extremity surgery.

Time and State Legislation Have Decreased Opioid Prescribing in Elective Foot and Ankle Surgery in the United States

BACKGROUND

Legislation in the United States has been enacted to reduce opioid overuse and abuse in the setting of the opioid epidemic, and a notable target has been opioid overprescription. However, the impact of this legislation on elective foot and ankle surgery is largely unknown. The purpose of this study was to evaluate the impact of opioid-limiting legislation on opioid prescribing in elective foot and ankle surgery.

METHODS

The 90-day perioperative opioid prescription filling in oxycodone 5-mg equivalents was identified in all patients 18 years of age and older undergoing nontrauma, nonarthroplasty foot and ankle surgery from 2010 to 2019 using a commercial database. States with and without legislation were identified, and opioid prescription filling before and after the legislation were tabulated. Unadjusted and adjusted analyses were performed to evaluate the impact of time and state legislation on perioperative opioid prescribing in this patient population.

RESULTS

Initial and cumulative opioid prescribing decreased significantly from 2010 to 2019 (39 vs 35.7 initial and 98.1 vs 55.7 cumulative). States with legislation had larger and more significant reductions in initial and cumulative opioid prescribing compared with states without legislation over similar time frames (41.6 to 35.1 with legislation vs 40.6 to 39.1 without legislation initial prescription filling volume and 87.7 to 62.8 vs 88.6 to 74.1 cumulative prescription filling volume).

CONCLUSION

State legislation and time have been associated with large, clinically relevant reductions in 90-day perioperative cumulative opioid prescription filling, although reductions in initial opioid prescription filing have remained low. These results encourage states without legislation to enact restraints to reduce the opioid epidemic.

LEVELS OF EVIDENCE

Level III: Retrospective, prognostic cohort study.

Validation of the Stopping Opioids After Surgery (SOS) Score for the Sustained Use of Prescription Opioids Following Orthopaedic Surgery

BACKGROUND

The Stopping Opioids after Surgery (SOS) score was developed to identify patients at risk for sustained opioid use following surgery. The SOS score has not been specifically validated for patients in a general orthopaedic context. Our primary objective was to validate the SOS score within this context.

METHODS

In this retrospective cohort study, we considered a broad array of representative orthopaedic procedures performed between January 1, 2018, and March 31, 2022. These procedures included rotator cuff repair, lumbar discectomy, lumbar fusion, total knee and total hip arthroplasty, open reduction and internal fixation (ORIF) of ankle fracture, ORIF of distal radial fracture, and anterior cruciate ligament reconstruction. The performance of the SOS score was evaluated by calculating the c-statistic, receiver operating characteristic curve, and the observed rates of sustained prescription opioid use (defined as uninterrupted prescriptions of opioids for ≥90 days) following surgery. For our sensitivity analysis, we compared these metrics among various time epochs related to the COVID-19 pandemic.

RESULTS

A total of 26,114 patients were included, of whom 51.6% were female and 78.1% were White. The median age was 63 years. The observed prevalence of sustained opioid use was 1.3% (95% confidence interval [CI], 1.2% to 1.5%) in the low-risk group (SOS score of <30), 7.4% (95% CI, 6.9% to 8.0%) in the medium-risk group (SOS score of 30 to 60), and 20.8% (95% CI, 17.7% to 24.2%) in the high-risk group (SOS score of >60). The performance of the SOS score in the overall group was strong, with a c-statistic of 0.82. The performance of the SOS score showed no evidence of worsening over time. The c-statistic was 0.79 before the COVID-19 pandemic and ranged from 0.77 to 0.80 throughout the waves of the pandemic.

CONCLUSIONS

We validated the use of the SOS score for sustained prescription opioid use following a diverse array of orthopaedic procedures across subspecialties. This tool is easy to implement for the purpose of prospectively identifying patients in musculoskeletal service lines who are at higher risk for sustained opioid use, thereby enabling the future implementation of upstream interventions and modifications to avert opioid abuse and to combat the opioid epidemic.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Bringing Opiates Off the Streets and Undertaking Excess Scripts: A novel opiate reclamation and prescription reduction program

BACKGROUND

Opioid diversion and misuse continue to present problems in modern medicine. The "opioid epidemic" has claimed more than 250,000 lives since 1999, with studies pointing to prescription opioids as the culprit for future opiate misuse. Currently, there are no well-described, data-driven processes to educate surgeons on reducing opiate prescribing, informed by personal practice patterns. We designed and implemented a novel opiate reclamation and prescription reduction program for surgeons to reclaim unused medications and decrease prescribing using individual provider data.

METHODS

We performed a prospective collection of all unused opiate pain medications for general surgery postoperative patients from July 15, 2020 to January 15, 2021. Patients brought their unused opiates to their routine postoperative follow-up appointment, where they were counted and disposed of in a secure drug take-back bin. Reclaimed opiates were totaled, analyzed, and reported to the providers, who used their individual reclamation rates to refine prescribing habits.

RESULTS

During the reclamation period, 168 operations were performed, with a total of 12,970 morphine milligram equivalents of opiate prescribed by 5 physicians. A total of 6,077.5 morphine milligram equivalents (46.9%) were reclaimed, which is the equivalent of 800 5-mg tablets of oxycodone. A review of these data led to a 30.9% decrease in opiate prescriptions by participating surgeons in addition to the reclamation of an additional 3,150 morphine milligram equivalents over the next 6 months.

CONCLUSION

Continuous monitoring of the medications returned by patients now continues to inform our providers' prescribing practices, decreases the amount of opiates in the community, and improves patient safety.

A Retrospective Study Analyzing Opioid Prescription Practices in Hand Surgery from 2013 to 2019

Background

The potential for opioid prescription medication addiction and abuse has been a growing concern in healthcare. It is not uncommon for hand surgery patients to be overprescribed opioid medication for postoperative pain management. The objective of this study was to characterize changes in opioid prescription practices of hand surgeons treating Medicare Part D patients from 2013 to 2019.

Methods

A retrospective analysis of Medicare Part D prescriber data from 2013 to 2019 was conducted. This database provides information on drugs paid for under the Medicare Part D Prescription Drug Program. For each prescriber and medication, the dataset includes the total number of prescriptions dispensed (original prescriptions and number of refills), and total medication cost.

Results

In 2013, the 10 most common medications prescribed totaled 114,409 prescriptions, with 89,701 (78.4%) opioid prescriptions. In 2019, the 10 most common medications prescribed totaled 164,955 prescriptions, with 109,665 (66.5%) opioid prescriptions. Although total opioid prescriptions dropped, there was a 22% increase in the total number of prescriptions written. The two most common medications prescribed, hydrocodone-acetaminophen and oxycodone-acetaminophen, totaled 75,796 in 2013, compared with 76,518 in 2019. The overall number of prescriptions for nonsteroidal anti-inflammatory drugs increased by 157%, and the percentage of total opioids prescribed declined by 7.9%.

Conclusions

The increase in total opioid prescriptions from 2013 to 2019 by hand surgeons in the Medicare Part D Prescription Drug Program lags behind the recommended shift to nonopioid pain management. The reasons for the overall rise in prescriptions deserve further exploration.

Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis

INTRODUCTION

Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals.

METHODS

This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient.

RESULTS

Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%).

CONCLUSIONS

Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.

Opioid prescription trends after ambulatory anterior cervical discectomy and fusion

BACKGROUND CONTEXT

Opioid utilization has been well studied for inpatient anterior cervical discectomy and fusion (ACDF). However, the amount and type of opioids prescribed following ambulatory ACDF and the associated risk of persistent use are largely unknown.

PURPOSE

To characterize opioid prescription filling following single-level ambulatory ACDF compared with inpatient procedures.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database.

OUTCOME MEASURES

Rate, amount, and type of perioperative opioid prescription.

METHODS

Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. Perioperative opioids were defined as opioid prescriptions 30 days before and 14 days after the procedure. Rate, amount, and type of opioid prescription were characterized. Multivariable analyses controlling for any differences in demographics and comorbidities between the two treatment groups were utilized to determine any association between surgical setting and persistent opioid use (defined as the patient still filling new opioid prescriptions >90 days postoperatively).

RESULTS

A total of 42,521 opioid-naive patients were identified, of which 2,850 were ambulatory and 39,671 were inpatient. Ambulatory ACDF was associated with slightly increased perioperative opioid prescription filling (52.7% vs 47.3% for inpatient procedures; p<.001). Among the 20,280 patients (47.7%) who filled perioperative opioid prescriptions, the average amount of opioids prescribed (in morphine milligram equivalents) was similar between ambulatory and inpatient procedures (550 vs 540, p=.413). There was no association between surgical setting and persistent opioid use in patients who filled a perioperative opioid prescription, even after controlling for comorbidities, (adjusted odds ratio, 1.15, p=.066).

CONCLUSIONS

Ambulatory ACDF patients who filled perioperative opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient procedures. Further, ambulatory ACDF does not appear to be a risk factor for persistent opioid use. These findings are important for patient counseling as well as support the safety profile of this new surgical pathway.

Opioid Requirement After Anterior Cruciate Ligament Surgery: Opioid Use After Anterior Cruciate Ligament Surgery Is Low With a Multimodal Approach, and Fifteen Oxycodone 5-mg Tablets Are Sufficient

Purpose

To prospectively determine opioid consumption in patients undergoing anterior cruciate ligament (ACL) repair and reconstruction and to develop evidence-based prescription guidelines following ACL surgery.

Methods

This multicenter prospective study enrolled patients undergoing ACL reconstruction and repair. Subject demographics and opioid prescriptions were recorded at enrollment. All patients were given education on opiate use and followed the same perioperative, multimodal analgesic regimen. Following surgery, patients were given postoperative "pain journals" to document visual analog scale pain scores and daily opioid consumption for the first 7 postoperative days and on postoperative visit at 14 days.

Results

In total, 50 patients were included in this analysis between the ages of 14 and 65 years. Patients were prescribed a median of 15 oxycodone 5-mg pills and consumed a median of 2 pill postoperatively (range 0-19 pills). 38% of patients consumed 0 opioid pills, 74% of patients consumed ≤5 opioid pills, and 96% of patients consumed ≤15 opioid pills. Patients reported a mean daily visual analog scale value of 2.8 of 10; mean satisfaction with pain management was high at 4.1/5 on a Likert satisfaction score. Overall, patients consumed a mean 34% of their opioid prescriptions, leaving 436 opioid pills not consumed.

Conclusions

This study suggests that current expert panels may be recommending an excessive volume of opioids. Based on our findings, we recommend that patients be prescribed no more than 15 Oxycodone 5-mg tablets following ACL surgery. Despite this lower volume prescription, mean pain scores remained below 3 of 10, patient satisfaction with pain control remained high, and 66% of opiate medication prescribed was not used.

Level of Evidence

II, prospective prognostic cohort investigation.

Perioperative Opioid Analgesics and Hallux Valgus Correction Surgery: Trends, Risk Factors for Prolonged Use and Complications

In the setting of an opioid epidemic, this study aims to provide evidence on opioid use trends, risk factors for prolonged use, and complications from perioperative opioid consumption in hallux valgus surgery. A national database was queried for patients who underwent hallux valgus correction. Regression analysis identified: (1) risk factors for prolonged postoperative narcotic use; and (2) association between preoperative/prolonged postoperative narcotic use and postoperative complications. A linear regression analysis was used to determine trends. About 20,749 patients were included, of which 3464 patients were prescribed narcotics preoperatively and 4339 were identified as prolonged postoperative narcotic prescription users. Preoperative prescriptions were identified as risk factors for prolonged use. Perioperative narcotic use was observed to be a risk factor for poor outcomes. About 21% of patients were identified as prolonged postoperative narcotic prescription users. Patients undergoing hallux valgus corrective surgery should be counseled regarding their increased risk of complications when using narcotics.

Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System

PURPOSE

We hypothesized that a pain management prescribing tool embedded in the electronic health record system of a multihospital health care system would decrease prescription opioids for postoperative pain by hand, orthopedic, plastic, and spine surgeons.

METHODS

A prescribing tool for postoperative pain was designed for hand, orthopedic, plastic, and spine surgeons and implemented into electronic discharge order sets in a 10-hospital health care system. Stakeholders were educated on tool use in person and/or by email on 2 occasions. A dashboard was created to monitor opioid pill quantities and morphine milligram equivalents (MMEs) prescribed. Overall compliance with the suggested opioid amounts was assessed for 20 months after tool implementation. A subgroup of 6 hand surgeons, one of whom was instrumental in designing the tool, were evaluated for MMEs prescribed, opioid refills, patient emergency room visits, and patient readmissions within 30 days after discharge. Comparisons in this subgroup were made from 12 months before to 15 months after tool implementation.

RESULTS

The mean system-wide compliance with the suggested opioid pill quantities and MMEs prescribed in all 4 specialties improved by less than 5%. In the subgroup of hand surgeons, 5 of whom championed tool use, prescribed MMEs decreased by 10% during each of the 4 quarters before launching the tool and contracted an additional 26% in the first quarter after tool implementation. Opioid refills held steady at 5%, and there were no emergency room visits or readmissions within 30 days after discharge in this patient subgroup.

CONCLUSIONS

The prescribing tool had a negligible impact on system-wide compliance with suggested prescription opioid pill quantities and MMEs. In a small group of surgeons who championed the use of the tool, there was a significant and sustained decline in MMEs prescribed without adversely impacting patient refills, emergency room visits, or readmissions.

CLINICAL RELEVANCE

An electronic prescribing tool to assist surgeons in lowering opioid prescription pill quantities and MMEs may have a negligible impact on prescribing behavior in a multihospital health care system.

The interobserver reliability of clinical relevance in orthopaedic research

PURPOSE

A ratio of observed difference (OD) over the 95% confidence interval (CI) has been shown to be strongly associated with the perceived clinical relevance (CR) of medical research results. The purpose of this study was to evaluate the association between the OD/CI ratio and perceived CR in orthopaedic research.

METHODS

Sixty-seven orthopaedic surgeons completed a survey with 15 study outcomes (mean difference and CI) and were asked if they perceived the findings as clinically relevant. The interobserver reliability of perceived CR and the association between CR and the OD/CI ratio and p-value were assessed.

RESULTS

The interobserver reliability of CR between respondents was moderate (kappa = 0.46, CI 0.45 to 0.48). P-values did not differ between results with and without CR (median difference (MD) - 0.12, CI - 0.74 to 0.0009, p = 0.07). The OD/CI ratio, however, was greater for results with CR (MD 1.01, CI 0.3 to 3.9, p = 0.004). The area under the curve (AUC) for the p-value and OD/CI ratio receiver operating characteristic (ROC) curves was 0.80 (p = 0.01) and 0.97 (p = 0.0003). The cutoff p -value and OD/CI ratio that maximized the sensitivity (SN) and specificity (SP) for CR were 0.001 (SN 80%, SP 80%) and 0.84 (SN 100%, SP 90%). The SN and SP of a p-value cutoff of 0.05 was 100% and 50%.

CONCLUSION

The interobserver reliability of the perceived CR of orthopaedic research findings was moderate. The OD/CI ratio, in contrast to the p-value, was strongly associated with perceived CR making it a potentially useful measure to evaluate research results.

Evaluation of a post-discharge pharmacist opioid review following total knee arthroplasty: a pre- and post-intervention cohort study

Background

More than 70% of patients continue to use opioid medications 3-weeks following total knee arthroplasty. Post-discharge pharmacist reviews improve medication management, however it’s effect on opioid usage is not known.

Aim

This study aimed to evaluate the impact of post-discharge pharmacist review on opioid use following a total knee arthroplasty.

Method

A pilot, cohort pre- and post-intervention study was undertaken on patients who had undergone a total knee arthroplasty and were supplied an opioid upon discharge from hospital. During the intervention, patients were contacted via telephone by a pharmacist approximately five days post-discharge to review analgesic usage, provide education and advice and communicate an opioid management plan to their general practitioner. The primary endpoint was the percentage of patients taking opioids 3-weeks post-discharge. Secondary endpoints included: percentage of patients obtaining an opioid refill; patient satisfaction with opioid supply and the pharmacist review.

Results

Pre- and post-intervention, 63 and 44 patients were included, respectively. The percentage of patients taking opioids 3-weeks post-discharge declined from 74.6 to 29.6% (p < 0.001) and the percentage requiring an opioid refill from their general practitioner declined from 71.4 to 36.4% (p  < 0.001). More patients were satisfied with opioid supply during the intervention period (79.5% cf. 47.6%, p = 0.001). Twenty-eight (63.6%) patients could recall the post-discharge pharmacist review, and all were either satisfied or extremely satisfied with the review.

Conclusion

Pharmacist-delivered post-discharge analgesia review reduced the percentage of patients taking opioids 3-weeks post-discharge following a total knee arthroplasty. This intervention has the potential to provide a smoother transition of care for patients supplied with opioids at the time of hospital discharge.

Use of Opioids in the Early Postoperative Period After Arthroscopic Rotator Cuff Repair: A Systematic Review

Background:

Postoperative treatment plans after orthopaedic procedures frequently include opioids for pain relief.

Purpose:

To evaluate opioid use in the early postoperative phase after arthroscopic rotator cuff repair (ARCR) to develop a procedure-specific understanding of the current role of opioids in pain management for this procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A PubMed search was used to identify eligible studies. Data on patient demographics, visual analog scale pain scores, and opioid use patterns (in morphine milligram equivalents [MMEs]) were collected and assessed. Cumulative MMEs were reported on postoperative day (POD) zero, and mean MMEs were reported on subsequent PODs (days 1, 2, 3, 5, 7, and 14). Metaregression, I² indices, and Cochran Q tests were used to evaluate study variation, heterogeneity, and variance.

Results:

A total of 1487 patients in 22 studies were included in the analysis. An estimated 51% (95% CI, 31%-70%) of patients with nerve blocks (NBs) were opioid-free through POD-0 versus 40% (95% CI, 1.2%-97%) of patients without NBs, which increased to 65% (95% CI, 55%-74%) versus 25% (95% CI, 1.7%-86%) by POD-1. Opioid requirements were highest in the first 72 hours after ARCR. NB use reduced opioid requirement on POD-0 compared with no NB use (15.8 vs 45.0 MMEs, respectively; P < .001) but did not reduce requirements after that. In addition, NB use led to a statistically significant increase in opioid requirements on POD-7 (28.6 vs 9.5 MMEs, respectively; P < .001). Using a model that assumes stable opioid requirements between our time points, weighted mean cumulative opioid consumption was 163 MMEs in the first week and 273 MMEs in the first 2 weeks (150 and 287 MMEs in patients with NB; 180 and 261 MMEs in patients without NB, respectively).

Conclusion:

Opioid use is relatively common in the early postoperative period after ARCR. Pain scores and opioid requirements may spike on POD-1; however, patients should be educated and reassured that they will gradually decrease usage over the initial 2-week postoperative period.

The Effect of Standardized Perioperative Patient Education on Opioid Use After Minor Soft Tissue Procedures Distal to the Wrist

PURPOSE

Several studies have explored opioid consumption and opioid prescriber education for upper extremity procedures; however, less literature has focused on patient-centered interventions and their impact on opioid consumption after surgery. The purpose of this study was to create a standardized perioperative patient education program regarding postoperative pain management after hand surgery and to determine if it could reduce opioid use after hand surgery.

METHODS

Patients scheduled to undergo elective outpatient hand surgery comprising minor soft tissue procedures at and distal to the wrist were randomized to receive pain management education or standard care. Before the surgery, all patients viewed a webinar with instructions for participation, whereas the education group received an additional 10 minutes of education on postoperative pain management and a pain management reference card for review after the surgery. All patients completed a postoperative daily log documenting the number of opioids consumed, other pain management modalities used, and pain scores. The primary outcome of the number of opioid pills consumed by the patients was compared between the groups. We constructed a linear regression model to determine the risk factors for postoperative opioid use after surgery.

RESULTS

One hundred seventy-four patients completed the study (n = 90 education group; n = 84 standard care group). Patients in the education group took significantly fewer opioid pills (median = 0, range 0-13) than those in the standard care group (median = 0.5, range 0-40). A linear regression model showed that average week-1 pain (B = 0.93; 95% confidence interval, 0.56-1.3) and the number of pills prescribed (B = 0.12; 95% confidence interval, 0.017-0.22) were predictive of greater opioid use.

CONCLUSIONS

Perioperative patient education significantly reduced postoperative opioid use following a minor soft tissue hand surgery, with greater than 70% of the patients taking no opioids.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Opioid Prescribing Patterns Among Orthopedic Hand Surgeons After Implementation of a Divisional Protocol

INTRODUCTION

Overprescribing contributes to the misuse and overuse of narcotics. We hypothesized that implementation of postoperative prescribing guidelines would consistently reduce the amount of opioids prescribed after ambulatory hand surgery.

METHODS

A divisional protocol was instituted in November 2018. A retrospective cohort study was designed to examine the policy's effects on postoperative prescribing. Postoperative opioid prescriptions for patients undergoing ambulatory hand surgery were evaluated 1 year before and 1 year after policy initiation. All prescriptions were converted into the total oral morphine equivalent (OME) prescribed.

RESULTS

A total of 1,672 surgeries were included. Six hundred sixty-one cases were in preimplementation group, and 1,011 cases were in the postimplementation group. The median of total OME decreased significantly after distribution of prescribing guidelines from 75 in the preimplementation group to 45 in the postimplementation group (p < .001) with significant reductions seen for carpal tunnel release (p < .001), trigger finger release (p < .001), distal radius open reduction internal fixation (p < .001), and finger closed reduction and pinning (p < .001). When categorized by procedure type, the median of total OME decreased from 75 to 30 for soft tissue procedures (p < .001) and from 120 to 100 for bony procedures (p < .001).

CONCLUSION

Divisional prescribing guidelines lead to consistent short-term to mid-term reductions in the amount of opioid medication prescribed postoperatively.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

OBJECTIVE

Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion.

METHODS

The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses.

RESULTS

In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001).

CONCLUSIONS

A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Evaluation of Prescribing Patterns Following Surgical Procedures in Opioid Naïve Patients at a Veterans Affairs Teaching Hospital

OBJECTIVES

To evaluate facility postoperative opioid prescribing patterns in comparison to published guidelines and adherence to opioid safety mandates.

METHODS

This quality analysis was performed between November 2019 and March 2020. Patients were identified to have been opioid naïve prior to receiving a new opioid prescription postoperatively during the study period. Patient charts were reviewed, and patients were contacted to collect desired data. Statistical analysis was performed to evaluate distributions of morphine equivalent daily dose and opioid day supply prescribed across study subpopulations.

RESULTS

Ninety-four of 100 prescriptions evaluated were determined to be within quantity or duration recommendations of the selected guideline. Statistical analysis found no significantly different distributions between the duration and quantity of opioid prescribed at discharge and patient-specific risk factors. Forty-eight patients did not use the entire quantity of the initial opioid prescription dispensed. Of those patients, 26 still had opioids within the home. Opioid risk review documentation was completed in 19 of 65 patients indicated for documentation.

CONCLUSION

Most opioid prescriptions provided within the study period aligned with recommendations from author-selected guidelines. However, a review of risk prior to opioid prescribing frequently was not performed. The number of patients utilizing less than 50% of prescribed opioids, and few refills indicate that reductions in opioids prescribed would improve safety for both patients and the surrounding community without increasing the risk for the under-treatment of postoperative pain. Improved prescribing habits and patient safety will be targeted through provider education regarding risk review documentation in opioid naïve patients.

Dramatic Reduction in Opioid Prescribing for Common Outpatient Orthopaedic Lower Extremity Surgical Procedures at a Louisiana University-Based Safety-Net Hospital After Enactment of Opioid-Limiting State Legislation

INTRODUCTION

The opioid epidemic in the United States has been fueled by overprescribing opioids, which is particularly apparent in orthopaedics. Stakeholders, including state legislatures, have attempted to curb opioid overprescribing to reduce related abuse/dependence, overdose deaths, and diversion.

OBJECTIVE

To examine trends in opioid prescribing for common outpatient lower extremity orthopaedic surgeries in a population vulnerable to prolonged opioid use before and after the enactment of a 2017 Louisiana state law limiting opioid prescribing for acute pain.

METHODS

Eligible patients were adults who underwent one of the five most common outpatient lower extremity orthopaedic surgeries done during 2013 to 2018 at an urban tertiary care academic medical center. Excluded were prisoners and patients who required inpatient hospitalization, had no documented discharge opioid prescription, or filled an opioid prescription unrelated to their orthopaedic procedure within 30 days before surgery.

RESULTS

During 2013 to 2018, 655 surgical procedures were done in 655 eligible patients, of whom 49% were Black and 54% were insured by Medicaid. The mean morphine milligram equivalent per discharge prescription decreased by almost 70% from 2014 to 2018. A statistically significant decrease in the mean morphine milligram equivalent per discharge prescription was observed in 2018 versus all previous years (P < 0.0001 for all) and in 2017 versus all previous years (P < 0.0001 for all). Patients receiving at least one new opioid prescription after their discharge prescription declined over time from a high of 50% in 2013 to a low of 19.3% in 2018 with a statistically significant effect over time (P < 0.0001).

DISCUSSION

Opioid prescribing for patients undergoing common outpatient lower extremity orthopaedic surgeries who were at high risk for prolonged opioid use markedly declined after the enactment of a state law limiting first-time opioid prescriptions to 7 days, requiring physicians to check the state's Prescription Monitoring Program database and mandating continuing education for opioid prescribers.

Discharge Opioid Prescribing Patterns in an Academic Orthopaedic Setting: Level of Training and Subspecialty Patterns

INTRODUCTION

Despite increased research on opioids in the orthopaedic literature, little is known of the prescribing practices of orthopaedic providers based on their level of training. The purpose of this study was to describe the discharge opioid prescribing patterns of orthopaedic providers, stratifying by level of training and orthopaedic subspecialty, within a single medical system.

METHODS

A retrospective review of orthopaedic surgical encounters was performed over a 1-year period for adults who received a discharge opioid prescription. Patient demographics and prescriber characteristics were collected, including the provider's level of training (attending, fellow, resident, physician assistant [PA], and nurse practitioner [NP]) and surgical subspecialty. Junior residents were postgraduate year 1 to 3, whereas senior residents/fellows were postgraduate year 4 to 6. Discharge opioids were converted to milligram morphine equivalents (MMEs). Overprescribing was defined as a prescribing more than a seven-day supply or >45 MMEs per day. Multivariable linear regression analysis determined the factors associated with discharge MMEs, whereas logistic regression determined the factors associated with overprescribing opioids.

RESULTS

Of the 3,786 patients reviewed, 1,500 met the criteria for inclusion in the study. The greatest proportion of opioid prescriptions was written by junior residents (33.9%), followed by NPs (30.1%), PAs (24.1%), senior residents/fellows (10.6%), and attendings (1.2%). Compared with junior residents, senior residents prescribed -59.4 MMEs, NPs prescribed +104 MMEs, and attendings prescribed +168 MMEs (P < 0.05), whereas PAs prescribed similar amounts (P > 0.05). Orthopaedic subspecialty was also predictive of discharge MMEs (P < 0.05). Senior residents and attendings were more likely to prescribe more than seven days of opioids (P < 0.05), whereas NPs and PAs were more likely to prescribe >45 MMEs per day (P < 0.05).

DISCUSSION

This study demonstrates significant variability in opioid prescribing practices according to provider level of training and subspecialty. National guidelines for opioid prescribing practices and educational programs may help reduce such variability.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Time to Stop Routinely Prescribing Opiates after Carpal Tunnel Release

BACKGROUND

North American surgeons continue to routinely order narcotic medication for postoperative pain relief after carpal tunnel surgery. For some patients, this instigates persistent use. This double-blind, multicenter trial investigated whether over-the-counter medications were inferior to opioid pain control after carpal tunnel release.

METHODS

Patients undergoing carpal tunnel release in five centers in Canada and the United States (n = 347) were randomly assigned to postoperative pain control with (opioid) hydrocodone/acetaminophen 5/325 mg versus over-the-counter ibuprofen/acetaminophen 600/325 mg. The two primary outcome measures were the Numeric Pain Rating Scale (0 to 10) and the six-item Patient-Reported Outcome Measurement Information System Pain Interference T-score. Secondary outcome measures were total medication used and overall satisfaction with pain medication management.

RESULTS

The authors found no significant differences between opioid and over-the-counter patients in the Numeric Pain Rating Scale scores, Pain Interference T-scores, number of doses of medication, or patient satisfaction. The highest Numeric Pain Rating Scale group difference was the night of surgery, when opiate patients had 0.9/10 more pain than over-the-counter patients. The highest group difference in Pain Interference T-scores (2.1) was on the day of surgery, when the opiate patients had more pain interference than the over-the-counter group. Patient nationality or sex did not generate significant pain score differences.

CONCLUSIONS

Pain management is not inferior for patients managed with over-the-counter acetaminophen/ibuprofen versus opioids. This study provides high-quality evidence that U.S. and Canadian surgeons should stop the routine prescription of narcotics after carpal tunnel surgery for patients who are not taking pain medicines daily before surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The Opioid Epidemic in the United States: Where Do Patients Requiring Elective Arthroplasty Stand?

INTRODUCTION

Over the past decade, awareness about opioid abuse in the general community and among prescribers has increased. This study evaluated how opioid prescribing patterns before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) may have changed during a recent 5-year period.

METHODS

The Truven Health MarketScan database were queried for patients who underwent elective THA and TKA for primary osteoarthritis between 2013 and 2017. The trend analysis evaluated for changes in opioid prescriptions and multivariate regression identified predictors for chronic postoperative opioid use.

RESULTS

Data were available for 27,908 THA patients and 47,220 TKA patients. The proportion of opioid naïve patients before THA or TKA increased significantly (P < 0.001). Median oral morphine equivalents prescribed during the first postoperative year after THA or TKA decreased significantly (P < 0.001). The proportion of patients with chronic postoperative opioid use also decreased for TKA patients (P < 0.001).

DISCUSSION

A notable, downward trend was seen in the proportion of patients who received opioids before elective arthroplasty, in the amount of opioid prescribed after surgery, and in TKA patients, the frequency of chronic opioid use after surgery. These findings reflect the effectiveness of efforts to combat the opioid epidemic after elective arthroplasty surgery.

Opioid prescribing in the U.S. Military Health System, 2014 to 2018: fewer prescriptions, fewer pills, and shorter treatment duration

ABSTRACT

Prescription opioids remain an important driver of the opioid crisis in the United States. The purpose of this study was to examine recent changes in opioid prescribing patterns in the Military Health System (MHS) which is a nationwide health system service active duty military personnel and civilian beneficiaries. All patients prescribed opioid analgesics by MHS providers and filled at MHS pharmacies between 2014 and 2018 were identified. Prescriptions were converted to oral morphine equivalents (OMEs) and categorized based on prescribing specialty and formulation. Total opioid prescription counts and opioid prescription counts weighted by the annual number of outpatient encounters for each specialty were calculated, as were total OMEs and daily OMEs per prescription. A total of 3,427,308 prescriptions were included. Primary care providers and surgeons wrote 47% and 29% of opioid prescriptions, respectively. Over the study period, there was a 56% decline in annual opioid prescriptions, 25% decline in median total OMEs, and a 57% decline in opioid prescriptions per patient encounter. The proportion of prescriptions written for >90 OMEs per day declined 21%. Declines in opioid prescriptions and quantities were observed in nearly all specialties over the study period. The results of this study suggest a broad-based shift towards less opioid prescribing.

Defining the Opioid Requirement in Anterior Cruciate Ligament Reconstruction

Introduction:

The amount and duration of opioids necessary after anterior cruciate ligament reconstruction (ACLR) are inadequately defined. This study sought to prospectively (1) define the amount and duration of opioid consumption, (2) investigate the relationship between preoperative pain expectation and postoperative satisfaction with pain management, and (3) identify risk factors for increased opioid use after ACLR.

Methods:

One hundred eight patients undergoing primary ACLR with hamstring graft were prospectively analyzed for preoperative pain expectation, using visual analog scale (VAS) rating, and postoperative satisfaction with pain management. Univariate and multivariate analyses were done to identify patient characteristics associated with satisfaction and/or amount and duration of opioid use.

Results:

Mean duration and cumulative intake of opioid consumption after ACLR were 5.3 days and 15.3 tablets, respectively. Patients expected moderate postoperative pain: mean preoperative VAS = 68.9. The preoperative VAS rating was associated with a significantly greater amount (P = 0.0265) and longer duration (P = 0.0212) of opioid consumption. Baseline opioid users took opioids for twice as long postoperatively (10.0 versus 5.0 days; P = 0.0149) and consumed twice as many tablets (29.3 versus 14.8 tablets; P = 0.0280) compared with opioid-naive patients.

Discussion:

This study demonstrated on average 15.3 opioid tablets over 5.3 days provided satisfactory pain management after ACLR. Risk factors for increased opioid consumption included preoperative opioid use.

National trends and prescription patterns in opiate analgesia for urolithiasis presenting to Emergency Departments: Analysis of the National Hospital Ambulatory Medical Care Survey, 2006-2018

OBJECTIVE

To analyze the National Hospital Ambulatory Medical Care Survey (NHAMCS) database to determine geographic and temporal trends, as well as variables associated with the likelihood of receiving an opioid prescription for urolithiasis in US EDs.

METHODS

All ED visits for urolithiasis between 2006-2018 in the NHAMCS database were analyzed. Age, race/ethnicity, insurance status, ED provider credentials, geographic region, and urban vs. rural hospital status were extracted. Linear regression was used to examine overall/regional trends in opioid prescriptions over time. Logistic regression was used to estimate factors associated with higher odds of receiving opioids.

RESULTS

Fourteen million visits were analyzed, of which, 79.1% (11.0 million) received an opioid prescription. From 2014-2018 there was a decline of 3.65%/year of the proportion of visits receiving an opioid prescription (R²=0.86, p=0.008). Non-Hispanic Black race was associated with a lower chance of receiving opioid prescription (OR=0.57, p=0.02) compared to Non-Hispanic Whites (NHW). Midwestern hospitals had higher odds of opioid prescription compared to the Northeast (OR=2.05, p=0.006). Rural hospitals had lower odds of opioid prescription compared to urban hospitals (OR=0.62, p=0.02).

CONCLUSION

Opioid prescriptions for patients presenting with urolithiasis to the ED have steadily declined from 2014-2018, except in the Midwest. NHW race, Midwest region, and urban EDs increase the likelihood of receiving opioids. Continued efforts encouraging non-opioid alternatives for urolithiasis are essential, specifically in Midwestern EDs, to mitigate the ongoing opioid epidemic in the US.

Opioid Prescribing after Carpal Tunnel Release: Analysis from the Michigan Collaborative Hand Initiative for Quality in Surgery

BACKGROUND

Little is known regarding the national practice patterns for postoperative opioid prescribing after carpal tunnel release, which is one of the most common surgical procedures performed. The authors sought to assess the rate of opioid prescribing after carpal tunnel release and patient-, surgeon-, and practice-level predictors of opioid prescriptions after surgery.

METHODS

The authors conducted a cohort study from the Michigan Collaborative Hand Initiative for Quality in Surgery, a national consortium of nine practices with 33 surgeons who prospectively collect data for the purpose of quality improvement. Patients were included who underwent carpal tunnel release between July 1, 2019, and December 31, 2019. Multilevel logistic regression was used to determine practice and surgeon variation in postoperative opioid prescribing related to patient characteristics.

RESULTS

Of the 648 patients with 792 operative hands, 52.9 percent were prescribed a postoperative opioid. After controlling for patient, surgeon, and practice characteristics, endoscopic carpal tunnel releases were associated with a decreased odds of receiving a postoperative opioid prescription compared to open carpal tunnel releases (OR, 0.19; 95 percent CI, 0.07 to 0.52). However, 57.4 percent of the variation in opioid prescribing was explained at the practice level, and 4.1 percent of the variation was explained at the surgeon level.

CONCLUSIONS

Practice-level prescribing patterns play a substantial role in opioid prescribing. National efforts should consider development of evidence-based opioid prescribing recommendations for carpal tunnel release that target all prescribers, including trainees and advanced practice providers. In addition, endoscopic carpal tunnel release may offer an opportunity to minimize opioid prescribing. The authors recommend that providers encourage the use of nonopioid analgesia and limit opioid prescriptions after carpal tunnel release.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Opioid prescription patterns among urologists as compiled from within Medicare

INTRODUCTION

We aimed to evaluate opioid prescribing patterns of urologists across the United States (U.S.) and the District of Columbia (D.C.) using publicly available data from Medicare Part D. Our secondary analysis was to identify any loco-regional trends that may exist within the U.S.

METHODS

We queried publicly reported information from the Part D prescriber database, which is compiled from beneficiaries enrolled within the Medicare Part D prescription drug program. Only providers with the specialty description of urologist were included in this study.

RESULTS

Between 2013 and 2017, a five-year average of 452 901 opioid claims by 9640 urologists - amounting to $5 357 114 USD and comprising 3.78% of all claims made - were identified. The state of Maine featured the highest percentage of opioid claims in relation to all claims (5.81%). West Virginia had the greatest average total opioid claims per provider (90), while Michigan featured the highest average proportion of opioid claims per provider (10.63%). The fewest opioid claims were processed within the Mid-Atlantic and New England regions.

CONCLUSIONS

A multitude of factors likely contributes to variability between states. Urologists should be increasingly aware of their individual prescription tendencies and use available drug monitoring programs to reduce unnecessary prescriptions, all while providing more targeted and appropriate pain management.

Treatment Decisions in Pediatric Sports Medicine: Do Personal and Professional Bias Affect Decision-Making?

Background:

Personal and professional biases can affect decision-making regarding important issues in pediatric sports medicine. Gaining insight into the opinions of health care professionals who specialize in pediatric sports medicine will provide information that may be useful for directing ongoing research in this field.

Hypothesis:

It was hypothesized that surgeons would demonstrate bias toward early surgical intervention versus nonsurgeons. In addition, it was hypothesized that youth sports medicine professionals who were parents of a child with a previous major sports injury or concussion would be less likely to allow their child to play American tackle football or return to football after a concussion.

Study Design:

Cross-sectional study.

Methods:

An online survey was provided to the active members of the Pediatric Research in Sports Medicine Society. We used both professional background information and responses to questions related to personal experiences with youth sports injuries to determine potential factors associated with underlying biases. Survey responses among subgroups were compared using the Fisher exact test. The Pearson correlation coefficient was used to evaluate years in practice versus opioid use.

Results:

Of the survey participants, 62.5% were pediatric surgeons, and 37.5% represented different nonsurgical youth sports medicine professions. Surgeons were less likely than nonsurgeons to agree to allow their child to return to football after sustaining a concussion and completing a concussion protocol (48% vs 76%, P = .013). Surgeons were more likely than nonsurgeons to agree to both elective shoulder stabilization after a first-time dislocation and elective drilling of a stable knee osteochondritis dissecans (OCD) before nonoperative treatment (41% vs 10%, P = .003 and 52% vs 23%, P = .013, respectively). Those who reported having a child with a concussion history were more likely to support him or her returning to football after a concussion (65% vs 33%, P = .026).

Conclusion:

Surgeons were more likely to favor elective shoulder-stabilization surgery after a first-time dislocation and drilling of a stable knee OCD instead of nonoperative management. Personal experience of having a child who sustained a major sports injury or concussion did not demonstrate a bias against participation in football or return to football after a concussion.

Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age

PURPOSE

Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use.

METHODS

A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60 years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1 year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15 months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage.

RESULTS

Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1 year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15 months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use.

CONCLUSION

Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use.

LEVEL OF EVIDENCE

Level III.

Opioid Naive Surgeons and Opioid-Tolerant Patients: Can Education Alter Prescribing Patterns to Total Knee Arthroplasty Patients?

Patterns of opioid overprescribing following arthroplasty likely developed given that poor pain control can diminish patient satisfaction, delay disposition, and lead to complications. Recently, interventions promoting responsible pain management have been described, however, most of the existing literature focuses on opioid naive patients. The aim of this study was to describe the effect of an educational intervention on opioid prescribing for opioid-tolerant patients undergoing primary total knee arthroplasty (TKA). As the start to a quality improvement initiative to reduce opioid overprescribing, a departmental grand rounds was conducted. Prescribing data, for the year before and after this intervention, were retrospectively collected for all opioid-tolerant patients undergoing primary TKA. Opioid prescribing data were standardized to mean morphine milligram equivalents (MME). Segmented time series regression was utilized to estimate the change in opioid prescribing associated with the intervention. A total of 508 opioid-tolerant patients underwent TKA at our institution during the study period. The intervention was associated with a statistically significant decrease of 468 mean MME (23%) from 2,062 to 1,594 (p = 0.005) in TKA patients. This study demonstrates that an educational intervention is associated with decreased opioid prescribing among opioid-tolerant TKA patients. While the effective management of these patients is challenging, surgeon education should be a key focus to optimizing their care.

Opioid requirement after rotator cuff repair is low with a multimodal approach to pain

BACKGROUND

Current practices may aim to blunt rather than understand postoperative pain. Perhaps the most common serious complication of arthroscopic rotator cuff repair (ARCR) is persistence of opiate medication intake. Patients still receive upwards of 80 oxycodone 5 mg pills, or 600 morphine milligram equivalents (MMEs), leading more than 20% of opioid-naïve subjects to continue to fill opioid prescriptions beyond 180 days after surgery. Developing evidence-based guidelines for narcotic prescription after ARCR presents an opportunity for orthopedic surgeons to address the opioid epidemic.

PURPOSE

The purpose of this study was (1) to prospectively determine the requirements for opiate medications after ARCR, and (2) to create an evidence-based guideline for postoperative prescription, in contrast to the anecdotal or expert panel recommendations that currently exist. We further investigated whether a liposomal bupivacaine (LB) interscalene never block (ISNB) would reduce pain and opiate consumption compared with standard bupivacaine ISNB (control) for ARCR.

METHODS

The study enrolled 100 patients who underwent primary ARCR surgery. Patients were provided with postoperative "pain journals" to document their daily pain on a numerical rating scale, satisfaction with pain management using the Likert scale, and track their daily oxycodone 5 mg pill consumption during the 14-day postoperative period. Enrolled patients were further randomized to receiving an LB (experimental) or standard bupivacaine (control) ISNB.

RESULTS

A total of 77% of all patients required fewer than 15 pills postoperatively. The LB group consumed an average of 1.7 fewer pills (13.0 MMEs) on postoperative day (POD) 1 (P = .02) and reported statistically lower pain during PODs 1 and 2 (P = .01 and P = .006), as well as cumulatively throughout the study period (P = .03). In addition, LB patients remained opioid-free at a higher rate (44% vs. 15% in controls, P = .03).

CONCLUSION

With a multimodal approach, the majority of patients undergoing ARCR can manage postoperative pain with 15 or fewer oxycodone 5 mg tablets (112.5 MMEs) and maintain a high degree of satisfaction. The addition of an LB ISNB may further reduce the consumption of postoperative narcotics compared with a standard ISNB. This study provides evidence that may be used for surgeon guidelines in the effort to reduce opioid prescriptions after ARCR.

Risk Factors for Increased Consumption of Narcotics After Hip Arthroscopy: A Prospective, Randomized Control Trial

INTRODUCTION

No accepted standard exists regarding the number of opioids to prescribe after many surgical procedures, and previous literature has indicated that the number of opioids prescribed influences the total number of pills consumed. The goal of this study was to investigate whether prescribing less opioids after hip arthroscopy results in less total postoperative utilization without compromising analgesia and identify risk factors for increased use.

METHODS

This study randomized 111 patients to receive either 30 or 60 tablets of hydrocodone/acetaminophen 10 to 325 mg after hip arthroscopy. Demographic information, pain instruments, and scores including International Hip Outcome Tool (iHOT-12) were collected preoperatively. Postoperatively, patients were contacted over the course of 3 weeks to determine their Numeric Pain Rating Scale scores, total number of tablets taken/leftover, and the last day that they required narcotic pain medications, which were calculated and compared for each group. Preoperative variables that increased the risk of higher narcotic pain medication requirements were assessed.

RESULTS

Patients in the 60-tablet group had significantly more tablets leftover than the 30-tablet group (49.5 versus 22.0, P < 0.001) and had no significant difference in Numeric Pain Rating Scale scores at 24 hours, 48 hours, or final follow-up. The 30- and 60-tablet groups demonstrated no significant difference in average tablets consumed (9.2 and 10.5, P = 0.60), respectively. Risk factors for increased postoperative opioid use included preoperative opioid use (B = 12.62, 95% confidence interval [CI], 6.28-18.96, P < 0.001) or muscle relaxant use (B = 22.45, 95% CI, 7.59-37.31, P < 0.0036) within 1 year preoperatively. Preoperative iHOT-12 scoring also significantly predicted postoperative opioid consumption in this cohort (B = -0.25, 95% CI, -0.45 to -0.036, P < 0.022).

CONCLUSION

The number of leftover tablets after hip arthroscopy can be significantly reduced by prescribing 30 tablets compared with 60 tablets without affecting postoperative pain control. Total tablets prescribed in this cohort did not affect total opioid utilization. Preoperative factors including opioid or muscle relaxant use and iHOT-12 scores can be used to predict postoperative opioid requirements.

Collaborative Creation of Regional Opioid-Prescribing Guidelines in Orthopaedics: Description of a Process, Measurement of Its Effectiveness, and Impact on Patient Satisfaction at a Participating Institution

Background:

Interventions designed to decrease opioid prescribing in orthopaedics have been effective when employed by specific institutions, subspecialties, and procedures. The objectives of this study were to examine the effectiveness of developing regional guidelines on opioid-prescribing practices after common orthopaedic surgical procedures, to determine whether compliance with the guidelines varied by procedure, and to measure the effect of the guidelines on patient satisfaction. All objectives were assessed at 1 participating institution.

Methods:

In February 2018, 53 orthopaedic surgeons representing 8 practices in Western New York attended a summit meeting to collaboratively create regional opioid-prescribing guidelines for 70 common orthopaedic procedures; these guidelines were later distributed electronically to all orthopaedists in Western New York. We retrospectively examined opioid-prescribing practices for adults undergoing an orthopaedic surgical procedure performed by 1 large practice in October 2017, 4 months before the summit meeting (776 patients), and in July 2018, 5 months after the summit meeting (653 patients). The number of opioid pills prescribed postoperatively and patient satisfaction were compared before and after the summit meeting using t tests.

Results:

The overall mean number of opioid pills (and standard deviation) prescribed postoperatively decreased from 69.5 ± 45.5 pills before the summit to 43.3 ± 28.0 pills after the summit (p < 0.0001). Sports medicine surgeons reduced the number of pills prescribed for anterior cruciate ligament reconstruction, arthroscopic rotator cuff repair, knee arthroscopy with meniscectomy, and shoulder arthroscopy with decompression; and adult reconstruction surgeons reduced the number of pills prescribed for total hip and knee arthroplasty. There was no change in the number of pills prescribed for lumbar spine fusion or implant removal. Satisfaction with the provider did not differ from before to after the summit; 75% of patients in the pre-summit group and 76% of patients in the post-summit group reported receiving excellent service (p = 0.62).

Conclusions:

The creation of regional opioid-prescribing guidelines in a collaborative fashion was assessed at 1 participating institution and was found to be effective at reducing the number of opioid pills prescribed by the orthopaedic surgeons participating in the project without affecting patient satisfaction, but adherence to the guidelines varied by procedure.

A Work in Progress: National Opioid Prescription Reductions Across Orthopaedic Subspecialties in a Contemporary Medicare Sample of 5,026,911 Claims

INTRODUCTION

As the opioid epidemic continues in the United States, efforts by orthopaedic surgeons to reduce opioid prescriptions remain critical. Although previous studies have demonstrated reductions in prescriptions across surgical specialties, there is limited information regarding contemporary trends in opioid prescriptions across orthopaedic subspecialties. Our analysis sought to estimate the frequency and trends of opioid prescriptions among Medicare Part D enrollees.

METHODS

The Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from Centers of Medicare and Medicare from 2014 to 2018 were analyzed. These data were merged with the National Provider Identifier Registry to identify the subspecialty of providers. Prescriber opioid prescription rate, days per claim, and claims per patient were calculated. Temporal trends were tested using linear regression. Poisson regression was used to calculate annual adjusted incidence rate ratios while controlling for year, surgeon sex, average patient comorbidity risk score, and average patient age.

RESULTS

We analyzed 5,026,911 opioid claims prescribed to 2,661,762 beneficiaries. Among all orthopaedic surgeons, the opioid prescription rate per 100 beneficiaries significantly decreased over the study period from 52.99 (95% CI, 52.6 to 53.37) to 44.50 (44.06 to 44.93) (P = 0.002). This decrease was observed for each subspecialty (all P values < 0.05). Similar significant reductions were appreciated across cohorts in the number of claims per beneficiary (all P values < 0.05). The opioid prescription rate among all orthopaedic surgeons and each subspecialty decreased significantly over the study period after controlling for various patient and surgeon characteristics (all P values < 0.05).

CONCLUSION

Orthopaedic surgeons across subspecialties have reduced their rates of opioid prescriptions over recent years. Although increased prescription-limiting legislation, alternative methods of pain control, and prescriber reeducation regarding the correct quantity of opioids needed for postoperative pain relief, ongoing research, and efforts are needed to translate these reductions into clinically meaningful changes.

Editorial Commentary: Opioid Sparing Through Patient Education Programs Is the Future for Sports Medicine and Arthroscopic Surgery to Optimize Outcome

Opioid research in sports medicine and arthroscopic surgery has exploded in the last few years. The literature definitively shows that preoperative opioid usage-in so-called opioid exposed, tolerant, and familiar patients-increases postoperative usage, readmission rates, and medical complications, yielding poorer outcome. Strategies to combat the deleterious effects of preoperative opioid use should be used to include ownership and acknowledgment of the problem, adherence to opioid prescribing protocols, and use of a multimodal anesthesia program that can mitigate the adverse effects by limiting abuse and preventing potential poor outcome. Adding patient education programs to change patient modifiable risk factors shows promise while simultaneously optimizing appropriate patient expectations that are linked to increased outcome. Thus, opioid mitigation, sparing, or altogether avoidance through improved education programs and opioid prescribing protocols will likely be the future of sports medicine and arthroscopic surgery to optimize patient outcome.

Standardizing Discharge Opioid Prescriptions in Kidney Transplant Patients Decreases Opioid Usage

BACKGROUND

Kidney transplant recipients are frequently prescribed excess opioids at discharge relative to their inpatient requirements. Recipients who fill prescriptions after transplant have an increased risk of death and graft loss. This study examined the impact of standardized prescriptions on discharge amount and number of outpatient refills.

MATERIALS AND METHODS

A historical cohort (Group 1) was compared to a cohort without patient-controlled analgesia (Group 2) and a cohort in which providers prescribed no opioids to patients who required none on the day prior to discharge, and 10 pills to those who required opioids on the day prior (Group 3). Demographics, oral morphine equivalents (OMEs) prescribed on the day prior to and at discharge, and outpatient refills were collected.

RESULTS

270 recipients were included. There was a nonsignificant trend towards lower OMEs on the day prior to discharge in Groups 2 and 3. Nonopioid adjunct use increased (P < 0.001). Discharge OMEs significantly decreased (mean 87.2 in Group 1, 62.8 in Group 2, 26.6 in Group 3, P< 0.001). The number of patients discharged without opioids increased (23.8% of Group 1, 37.5% of Group 2, 60.6% of Group 3, P < 0.001). Group 3, Asian descent, and lower OMEs on the day prior were factors significantly associated with decreased discharge OMEs on multivariable linear regression. Twelve percent of Group 2 and 2% of Group 3 patients received an outpatient refill (P = 0.02).

CONCLUSIONS

A protocol targeting discharge opioids significantly reduced the amount of opioids prescribed in kidney transplant recipients; most patients subsequently received no opioids at discharge.

Institutional reductions in opioid prescribing do not change patient satisfaction on Press Ganey surveys after total shoulder arthroplasty

BACKGROUND

With an ongoing opioid epidemic in the United States, it is important to examine if decreased opioid prescribing can affect patient experience, namely satisfaction with pain control.

PURPOSE

The purpose of this study was to investigate what effect, if any, decreased opioid prescribing after total shoulder arthroplasty had on Press Ganey satisfaction surveys.

METHODS

A retrospective review was conducted on patients who underwent primary anatomic or reverse total shoulder arthroplasty between October 2014 and October 2019. Patients with complete Press Ganey survey information and no history of trauma, fracture, connective tissue disease, or prior shoulder arthroplasty surgery were included in the analysis. Patients were segregated into 2 groups, pre-protocol and post-protocol, based on the date of surgery relative to implementation of an institutional opioid reduction protocol, which occurred in October 2018. Prescriptions were converted to morphine milligram equivalents (MME) for direct comparison between different opioid medications.

RESULTS

A total of 201 patients met inclusion criteria, and there were 110 reverse total shoulder arthroplasties and 91 anatomic total shoulder arthroplasties. Average opioids prescribed on discharge for the pre-protocol group were 426.3 ± 295 MME (equivalent to 56.8 tablets of oxycodone 5 mg), whereas after the initiation of the protocol, they were 193.8 ± 199 MME (equivalent to 25.8 tablets of oxycodone 5 mg); P < .0001. Average satisfaction with pain control did not change significantly between pre-protocol and post-protocol (4.71 ± 0.65 pre-protocol and 4.74 ± 0.44 post-protocol, P = .82).

CONCLUSION

A reduction in opioids prescribed after a total shoulder replacement is not associated with any negative effects on patient satisfaction, as measured by the Press Ganey survey.

The effect of the orthopaedic trauma association's (OTA) pain management guidelines on opioid prescriptions, pain control, and refills in outpatient orthopaedic trauma surgery

PURPOSE

To determine the effect of the Orthopaedic Trauma Association (OTA) pain management guidelines for acute musculoskeletal injuries on opioid prescription sizes, pain control, and refills.

METHODS

A prospective cohort study was performed at an academic urban level 1 trauma center. 90 patients undergoing outpatient orthopaedic trauma surgery were enrolled before and after the implementation of the OTA pain management guidelines. Adherence to guidelines, pain visual analog scale, and refills were recorded postoperatively and at the 2- and 6-week follow-up visit.

RESULTS

After implementation of the guidelines, the number of patients receiving oxycodone decreased from 100 to 27%, with these patients receiving the less potent hydrocodone, instead. The discharge morphine equivalent dose (MED) decreased from a median (interquartile range) of 225 (169-300) to 140 mg (140-210) (p < 0.001). More patients required refills in the guidelines group (42% vs. 20%), resulting in no difference in total MED prescribed (210 (140-280) vs. 225 (169-307)). Adherence to the guidelines occurred in 66% of patients. As-treated analysis of patients with adherent and non-adherent prescriptions found no detectable difference in pain control, number of opioid pills used, or refills at the 2-week and 6-week follow-up.

CONCLUSIONS

In the midst of a national opioid crisis, adoption of the OTA's pain management guidelines for orthopaedic trauma surgery warrants further research to determine if it's implementation can reduce the size, variability, and duration of opioid prescriptions.

LEVEL OF EVIDENCE

Level II, prospective cohort.

Reduced opioid prescribing following arthroscopic meniscectomy does not negatively impact patient satisfaction

BACKGROUND

Prior research has demonstrated that physician desire to optimize patient satisfaction is a cause of over-prescription of opioid medications in the healthcare setting. The purpose of this study was to investigate what effect, if any, decreased opioid prescribing following arthroscopic meniscectomy had on Press-Ganey (PG) satisfaction survey scores.

METHODS

A retrospective review of prospectively-collected data was conducted on patients who underwent arthroscopic meniscectomy between October2014-October2019. Inclusion criteria consisted of complete PG information, no history of trauma, connective tissue disease, or prior knee surgery. Groups were separated based on date of surgery relative to implementation of an institutional opioid reduction policy which occurred on October 1, 2018. Prescriptions were converted to milligram-morphine-equivalents (MME) for direct comparison between opioids. Minimal-Detectable-Change (MDC) was calculated to evaluate clinical significance of any statistically significant findings.

RESULTS

554 patients were included in this analysis (452pre-protocol, 102post-protocol). The groups did not differ statistically (p > 0.05) with respect to any patient demographics (age, BMI, sex, prior opioid use, opioid naivete) with the exception of smoking history; 54.4% in the pre-protocol group and 32.4%in the post-protocol group; p < 0.001. Mean discharge dose for the pre-protocol group was 229.3 ± 141MME, and 80.05 ± 82.7MME post-protocol; P < 0.0001. There were no statistically significant differences between pre-and-post-protocol satisfaction with pain control scores; P = 0.15. The differences between satisfaction with pain control did not meet clinical or statistical significance, based on a calculated MDC = 0.368. Among pre-protocol patients, 372(82.3%) gave a "top box" response to the question "degree-to-which-your-pain-was-controlled", compared to 91(89.2%) from the post-protocol group; P = 0.10.

CONCLUSION

A reduction in opioids prescribed after arthroscopic meniscectomy was not associated with any difference in patient satisfaction with pain management, as measured by the Press-Ganey survey. LOE: 3.

Opioid Consumption After Knee Arthroscopy

PURPOSE

To prospectively observe opioid consumption in patients undergoing knee arthroscopy and to create an evidence-based guideline for opioid prescription.

METHODS

This prospective multicenter observational study enrolled patients undergoing outpatient knee arthroscopy for meniscal repair, meniscectomy, or chondroplasty. Patients were provided with a pain journal to record postoperative opioid consumption, Numeric Pain Rating Scale (NPRS) pain scores, and Likert scale satisfaction scores for 1 week postoperatively. State databases were reviewed for additional opioid prescriptions.

RESULTS

One hundred patients were included in this study. Patients were prescribed a median of 5 pills (37.5 oral morphine equivalent [OME]). Median postoperative opioid consumption was 0 pills, with a mean of 0.6 pills (4.4 OME), and 74% of patients did not consume any opioid medication postoperatively. All patients consumed ≤5 pills (37.5 OME), and no patient required a refill. Patients reported a mean daily NPRS value of 1.9 out of 10 and a mean Likert score of 4.4 out of 5.

CONCLUSION

We found that current opioid prescribing habits exceed the need for postoperative pain management. Overall, all patients consumed ≤5 opioid pills, and 92% of patients discontinued opioids by the second postoperative day. In spite of the low prescription quantity, patients reported high satisfaction rates and low NPRS pain scores and required no refills. Therefore, we recommend that patients undergoing knee arthroscopy are prescribed no more than 5 oxycodone 5-mg pills.

LEVEL OF EVIDENCE

II, prospective prognostic cohort investigation.

Institutional Reductions in Opioid Prescribing Following Hip Arthroscopy Do Not Change Patient Satisfaction Scores

Purpose

To investigate what effect decreased opioid prescribing following hip arthroscopy had on Press-Ganey satisfaction survey scores.

Methods

A retrospective review of prospectively collected data was conducted on patients who underwent primary hip arthroscopy for femoroacetabular impingement between October 2014 and October 2019. Inclusion criteria consisted of complete Press-Ganey survey information, no history of trauma, fracture, connective tissue disease, developmental hip dysplasia, autoimmune disease, or previous hip arthroscopy. Groups were separated based on date of surgery relative to implementation of an institutional opioid reduction policy that occurred in October 2018. Prescriptions were converted to milligram morphine equivalents (MME) for direct comparison between different opioids.

Results

A total of 113 patients met inclusion criteria, 88 preprotocol and 25 postprotocol. There were no statistically significant differences between groups with respect to patient demographics or intraoperative pathologies (P > .05). Average opioid prescription dropped from 249.6 ± 152 MME (equivalent to 33.3 tablets of oxycodone 5 mg) preprotocol to 108.6 ± 84.7 MME (equivalent to 14.5 tablets of oxycodone 5 mg) postprotocol; P = .0002. There were no statistically significant differences in Press-Ganey survey scores between pre- and postprotocol groups (P > .05).

Conclusions

A reduction in opioids prescribed after a hip arthroscopy is not associated with any statistically significant difference in patient satisfaction with pain management, as measured by the Press-Ganey survey.

Level of Evidence

Level III, retrospective comparative study.

Decreased Prescribing of Postoperative Opioids in Pediatric ACL Reconstruction: Treatment Trends at a Single Center

BACKGROUND

Anterior cruciate ligament (ACL) injury is common in the pediatric population. Pain control after ACL reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Pain management practices are believed to have evolved in recent years to limit unnecessary exposure to risks associated with opioid use in this vulnerable population.

PURPOSE

To describe trends in postoperative opioid prescribing and assess factors including obtaining consent for opioid prescribing for minors that may have mitigated excessive prescription of opioids.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This is a retrospective review of a consecutive series of pediatric patients (<18 years) undergoing primary ACLR within an urban academic hospital system over a 5-year period (2014-2018). The study period included the gradual introduction of preoperative consenting for opioid use in minors as mandated by state law in 2016. Patient characteristics, surgical details, presence of a signed consent form to prescribe opioid medications, prescribed postoperative medications, prescriber, and indicators of inadequate pain control were collected. Univariate and multivariate analyses were performed to determine factors associated with reduced postoperative opioid prescribing.

RESULTS

This study included 687 patients with a mean age of 15.1 ± 1.9 years, with less than one-third of patients having preoperative consent forms to prescribe opioid medications. Postoperative prescribing trends demonstrated a decline in the number of opioid doses provided and increased utilization of nonopioid medications. Patients who received preoperative opioid counseling and signed a consent form were prescribed fewer opioids and had a smaller number of unscheduled contacts for poorly controlled pain. Univariate analyses identified multiple predictors of the number of opioid doses prescribed postoperatively. Obtaining preoperative consent to prescribe opioids and ambulatory surgery center location were found to be independent predictors of prescribed doses in the multivariate analysis.

CONCLUSION

The quantity of opioid medication prescribed for pain management after pediatric ACLR at our institution has declined in recent years. This appears to be, in part, related to state-mandated preoperative counseling about opioid use, signing of a consent form by the parent(s) or guardian(s) to prescribe opioids to minors, and encouragement toward the use of nonopioid medications when possible. Preoperative opioid use discussions in the pediatric population may be useful in reducing opioid overprescription and utilization in this population.

Longitudinal impact of a pre-populated default quantity on emergency department opioid prescriptions

OBJECTIVE

Previously published studies indicate that a pre-populated default quantity may decrease opioid amounts on discharge prescriptions from the emergency department (ED). However, the longitudinal effect of defaulted quantities has not been described in the literature.

METHODS

A retrospective review of electronic health record data from visits to 4 hospital EDs in a community health system examined opioid prescription dispense quantities 3.5 years pre- and 6.5 years post-implementation of a defaulted dispense quantity of seventeen. The primary purpose was to determine the percentage of ED discharge opioid prescriptions containing the prepopulated default dispense quantity after implementation. The longitudinal effect of a default quantity implementation on the average quantity prescribed (normalized per 1000 visits) was examined by comparing the pre-implementation period (January 1, 2009-July 31, 2012) to the post-implementation period (August 1, 2012-June 30, 2018).

RESULTS

After implementation in 2012, the acceptance rate of the default dispense quantity increased each year, up to 48% in 2016 and maintained through 2018. A significant decrease in prescribed opioid quantities post-default quantity implementation was sustained, with the average quantity prescribed from 2015-2018 maintained at 17 or lower.

CONCLUSION

A pre-populated default quantity impacts discharge opioid prescribing as evidenced by a high sustained rate of prescriber utilization over years and reduction in the per prescription average pill quantity. The acceptance of a pre-populated default quantity may allow for selection of even a lower quantity to influence prescribing patterns of opioid analgesics.

"It's Like Learning by the Seat of Your Pants": Surgeons Lack Formal Training in Opioid Prescribing

OBJECTIVE

To determine the training surgical residents and faculty receive on opioid prescribing, and to identify opportunities for curricula development to fill training gaps.

DESIGN

We conducted qualitative semi-structured interviews and surveys. After applying an overarching organizational framework, we used an iterative, team-based process to develop relevant inductive codes. We then performed thematic analyses to identify and catalogue critical domains related to surgeons' education about opioid prescribing.

SETTING

Tertiary care academic medical center.

PARTICIPANTS

Maximum variation purposive sampling was used to recruit general surgery residents and surgical faculty members.

RESULTS

We interviewed 21 attending surgeons and 20 surgical residents. Surgeons reported minimal formal training on pain management and prescribing opioids. A minority of individuals described receiving opioid training in the form of continuing medical education, intern boot camp sessions, and medical school classes. Participants compensated for the lack of formal training during residency by informally learning from senior residents, consulting pain specialists, and seeking external learning resources. Increased surgical experience was correlated with increased comfort with pain management. A majority of surgeons desired formal training. The most commonly requested educational resources were opioid prescribing guidelines for common operations and recommendations for treating chronic pain patients. Residents requested that training occur early in residency to maximize the benefits received. Based on these findings, we developed a conceptual framework to explain how surgeons learn to prescribe opioids and to highlight opportunities for improvement.

CONCLUSIONS

Although surgeons routinely prescribe opioids and desire education on opioids, a majority of them do not receive any training. Instituting formal educational programs is critical for improving opioid prescribing practices among surgeons.These programs should include standard prescribing guidelines and address management of acute postoperative pain in patients with chronic pain.

Opioid Prescribing Patterns in Orthopaedic Surgery Patients: the Effect of New York State Regulations and Institutional Initiatives

BACKGROUND

The opioid epidemic in the United States is a public health crisis. As a result, regulatory agencies, including state governments, have enacted initiatives to decrease the use of opioids in the perioperative setting. The purpose of this study was to compare opioid utilization in orthopaedic surgery patients at discrete points after implementation of State regulatory and institution/physician-led initiatives to decrease opioid utilization in the perioperative period.

METHODS

We reviewed the electronic medication orders for all patients who underwent orthopaedic surgery procedures between September 2015 and June 2018 at our urban academic medical center. The outcome measures were the number of patients who were prescribed opioid medications, duration of prescription (days), and average milligram morphine equivalents prescribed. Patients were divided into three time cohorts to assess the effect of the NY State (NYS) policy and institutional initiatives to decrease opioid utilization.

RESULTS

A total of 20,483 patients met the inclusion criteria over all three time cohorts. After the initiation of the NYS 7-day supply legislation, there was a decrease in the average supply of opioids prescribed from 10.1 to 7.6 days and the average daily milligram morphine equivalent decreased from 67.9 to 56.7 mg (P < 0.0001). However, with the combination of physician education and surgeon-led institutional initiatives, the percentage of patients who were prescribed opioids decreased by over 10% (96% to 84%), with continued decrease in duration of prescription by 1.0 to 6.4 days (P < 0.0001).

CONCLUSIONS

The addition of institution-led initiatives and education programs to previously established government-led prescription limits produced a substantial reduction in the amount of opioids prescribed to orthopaedic surgery patients in the perioperative period. Although mandatory limits set by the state government resulted in a decreased amount of opioid medications being prescribed per patient, it was only after the introduction of educational programs and institution- and physician-led programs that perioperative patient exposure to opioids decreased.

LEVEL OF EVIDENCE

Level III.