Less is more: limiting narcotic prescription quantities for common orthopedic procedures

Does dehydration prior to primary total joint arthroplasty increase risk of perioperative complications?

BACKGROUND

Prior studies have suggested that preoperative dehydration increases odds of perioperative complications in several areas of orthopedic surgery. This study aimed to evaluate whether preoperative hydration status is associated with the incidence of short-term complications after primary total joint arthroplasty.

METHODS

The 2012-2019 National Surgical Quality Improvement Program (NSQIP) database was used to explore the relationship between preoperative dehydration (ratio of preoperative BUN divided by preoperative Creatinine (BUN/Creatinine) > 20) and perioperative outcomes of total hip (THA) and total knee arthroplasty (TKA) patients. Univariate comparisons and multivariate regression analyses were conducted to identify specific complications that occurred more often in patients with preoperative dehydration.

RESULTS

Of 188,629 THA and 332,485 TKA patients, 46.3 and 47.0% had preoperative dehydration, respectively. After controlling for demographics and comorbidities, dehydrated THA patients were no more likely to experience a complication compared to their non-dehydrated counterparts (relative risk [RR] = 0.97, 99.7% Confidence Interval [CI]: 0.92-1.03, P = 0.138) nor increased risk of blood transfusion (RR = 1.02, CI = 0.96-1.08, P = 0.408). Similar to THA patients, dehydrated TKA patients were not more likely to have a complication after surgery (RR = 0.97, CI = 0.92-1.03, P = 0.138) and were at no greater risk of transfusion (RR = 1.02, CI = 0.96-1.07, P = 0.408). A sub-analysis covering only patients with BUN and Cr values determined within 24 h after surgery was performed and similarly found no significant increase in perioperative complications or transfusion.

CONCLUSION

Overall, preoperative dehydration in patients undergoing THA/TKA did not appear to increase risk of transfusion or other perioperative complications. Further research is needed to characterize the role of hydration prior to elective total joint arthroplasty.

The Effect of Preoperative Opioid Education on Opioid Consumption After Outpatient Orthopedic Surgery: A Prospective Randomized Trial

Pain management and opioid consumption following outpatient orthopedic surgery may be influenced by several variables, including knowledge of safe opioid use. A prospective randomized study was undertaken to understand the effect of preoperative opioid education on opioid consumption following outpatient orthopedic surgeries. A total of 237 patients undergoing outpatient orthopedic surgeries were prospectively randomized to receive preoperative opioid education or not. Postoperative data collected included the number of pills taken, daily visual analog scale (VAS) pain scores, adverse events, and attitude toward the pain experience. A total of 107 patients were randomized to receive preoperative education and 130 to not receive preoperative education. On average, 27 pills were prescribed to each patient. The preoperative opioid education group consumed significantly fewer opioids (6 pills) when compared with the group not receiving education (12 pills) (P<.05). The findings were the same with upper and lower extremity surgeries. Overall, the 2 groups of patients had similar daily VAS scores and were satisfied with their postoperative pain experience irrespective of opioid education. Of the total opioid pills prescribed during the study, only 46% were ultimately consumed. Preoperative education significantly reduced the number of prescription opioid pills and total morphine equivalents consumed by patients in the period following outpatient orthopedic surgery, with no negative effects on pain experience. This finding was consistent in both upper and lower extremity surgery. Approximately twice the number of opioids were prescribed than ultimately consumed by patients. [Orthopedics. 2021;44(2):123-127.].

Opioid Prescription After Carpal Tunnel Release Is Declining Independent of State Laws

BACKGROUND

The opioid misuse crisis focused attention on opioid overprescribing prompting legislation, limiting prescribing. The purpose of this study was to evaluate of opioid filling surrounding carpal tunnel release (CTR) with the hypothesis that filling has decreased in response to state legislation.

METHODS

This is a retrospective, observational study of initial discharge, 30-day, 90-day, and 1-year cumulative opioid filling after CTR in a commercial insurance database between 2010 and 2018. All patients aged 18 and older undergoing CTR and with active insurance status for 6 months preoperative through 30 days, 90 days, and 1 year postoperative were considered for inclusion. Patients undergoing same-day distal radius fracture fixation were excluded. Initial and cumulative perioperative patient, state, and year-level opioid filling rates and volumes in oxycodone 5 mg equivalents (oxycodone 5-mg pills) were evaluated.

RESULTS

Patients filled mean volumes of 33, 72, and 144 oxycodone 5-mg pills in the initial prescription, by 90 days post-op and by 1 year post-op, respectively. First prescription opioid filling volume (35 oxycodone 5-mg pills 2010 and 27 oxycodone 5-mg pills 2018, P < 0.001) and cumulative 90-day filling (96 oxycodone 5-mg pills 2010 and 56 oxycodone 5-mg pills 2018, P < 0.001) have decreased significantly from 2010 to 2018. Ten of 24 (41.7%) of states with opioid-limiting legislation had large (>5 oxycodone 5-mg pills), significant reductions in initial opioid filling volume after legislation. Five of 13 (38.5%) states without opioid-limiting legislation had similar reductions during the study period. Thirteen of 24 (54.2%) states with opioid-limiting legislation had large, notable reductions in 90-day opioid filling volume after legislation. Six of 13 (46.2%) states without opioid-limiting legislation had similar reductions during the study period.

CONCLUSION

Initial and cumulative opioid filling surrounding CTR has decreased significantly since 2010. However, opioid legislation did not result in substantial changes in rates of large, significant reductions in state-specific opioid prescribing.

Efficacy of Anti-inflammatory Treatment Versus Rescue Analgesia After Arthroscopic Partial Meniscectomy in Nonarthritic Knees: A 3-Arm Controlled Study

Background

There is currently no consensus regarding the appropriate treatment for postoperative pain after arthroscopic partial meniscectomy (APM). Prescribing a mild non-anti-inflammatory protocol of rescue analgesia may be sufficient to avoid the side effects of opioids or anti-inflammatories.

Purpose/Hypothesis

The purpose was to compare the efficacy of pain reduction after APM in nonarthritic knees using betamethasone or celecoxib as anti-inflammatory analgesics versus acetaminophen or tramadol as rescue analgesics. The hypothesis was that there is no advantage for anti-inflammatories in achieving postoperative immediate pain relief after APM in nonarthritic knees compared with a simple nonopioid treatment.

Study Design

Cohort study; Level of evidence, 2.

Methods

This 3-arm controlled study evaluated postoperative pain levels and analgesic consumption in patients who underwent primary APM (under general anesthesia) at a single institution from December 2018 to December 2019. Patients were prospectively divided into 3 treatment groups: (1) betamethasone injection at the end of the procedure, (2) oral celecoxib prescription, or (3) neither treatment (control). All groups were instructed to take supplementary acetaminophen as needed. Patients were also allowed to take tramadol as needed to evaluate the need for opioids. At postoperative weeks 1, 2, and 3, patients completed the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, and results were compared between time points and groups.

Results

A total of 99 patients were included in the treatment groups: betamethasone group (32 patients), celecoxib group (30 patients), and control group (37 patients). At baseline, there were no statistically significant differences between the groups in age, sex, body mass index, level of activity, comorbidities, or surgical findings. KOOS Pain scores improved at every time point for all 3 groups (P < .001), and no differences in scores were observed among groups. The consumption of acetaminophen or tramadol as rescue analgesia throughout the follow-up period was negligible among groups.

Conclusion

During the first 3 postoperative weeks after APM in nonarthritic knees, pain was efficiently controlled by betamethasone or celecoxib; however, pain was also efficiently controlled by minimal consumption of acetaminophen with negligible use of tramadol. Therefore, acetaminophen could be prescribed as an effective first-line postoperative analgesic after APM.

Persistent opioid use after surgical treatment of paediatric fracture

BACKGROUND

The opioid epidemic is one of the most pressing public health crises in the USA. With fractures being amongst the most common reasons for a child to require surgical intervention and receive post-surgical pain management, characterisation of opioid prescription patterns and risk factors is critical. We hypothesised that the numbers of paediatric patients receiving opioids, or who developed persistent opioid use, are significant, and a number of risk factors for persistent opioid use could be identified.

METHODS

We conducted a retrospective population-based cohort study. National claims data from the Truven Health Analytics® MarketScan database were used to (i) characterise opioid prescription patterns and (ii) describe the epidemiology and risk factors for single use and persistent use of opioids amongst paediatric patients who underwent surgical intervention for fracture treatment.

RESULTS

Amongst 303 335 patients, 21.5% received at least one opioid prescription within 6 months after surgery, and 1671 (0.6%) developed persistent opioid use. Risk factors for persistent opioid use include older age; female sex; lower extremity trauma; surgeries involving the spine, rib cage, or head; closed fracture treatment; earlier surgery years; previous use of opioid; and higher comorbidity burden.

CONCLUSIONS

Amongst a cohort of paediatric patients who underwent surgical fracture treatment, 21.5% filled at least one opioid prescription, and 0.6% (N=1671) filled at least one more opioid prescription between 3 and 6 months after surgery. Understanding risk factors related to persistent opioid use can help clinicians devise strategies to counter the development of persistent opioid use for paediatric patients.

Opioid Use After Common Sports Medicine Procedures: A Systematic Review

CONTEXT

The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America.

OBJECTIVE

To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures.

DATA SOURCES

A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018.

STUDY SELECTION

Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies.

RESULTS

A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill.

CONCLUSION

Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.

Prospective Study of Acute Opioid Use After Adolescent Anterior Cruciate Ligament Reconstruction Shows No Effect From Patient- or Surgical-Related Factors

INTRODUCTION

Patient-reported pain scores and opioid use have not been quantified after outpatient adolescent anterior cruciate ligament reconstruction (ACLR).

METHODS

Patients aged 12 to 18 years undergoing primary isolated ACLR, with or without meniscal treatment, were prospectively recruited. Patients actively taking opioids or with previous extended use of opioids were excluded. Two orthopaedic surgeons performed ACLR and determined the use of a hamstring or bone-patellar tendon-bone autograft. For postoperative pain management, patients were prescribed 40 tablets of hydrocodone/acetaminophen 5/325 mg. Patients were instructed to document daily pill consumption and side effects through a daily log for 6 weeks. Patients completed the American Pain Society Patient Outcome Questionnaire at the end of weeks 1 and 6.

RESULTS

One hundred three patients were enrolled, with age: 12.5 to 18.9 years (mean 16.2 y ± 1.3), weight: 41.3 to 113.6 kg (mean 72.4 kg ± 17.2), and body mass index: 17.8 to 40.1 (mean 25.9 ± 4.9). Sixty-nine patients received a hamstring autograft, and 34 received a bone-patellar tendon-bone autograft. Fifty-six received additional meniscal procedures. The median number of postoperative opioids taken by patients was 17 (range 0 to 40). No notable differences were found in total pill consumption with regard to age, weight, body mass index, sex, block type, autograft type, or meniscal treatment at 1 week post-op or 6 weeks post-op. No correlation was found between the self-reported "worst pain in the past 24 hours" at the end of the first postoperative week or after 6 weeks (r = 0.112, P = 0.26, and r = 0.093, P = 0.36). No correlation was found between the level of satisfaction with pain treatment and total number of pills taken during the first postoperative week or at the end of 6 weeks (r = -0.090, P = 0.37, and r = -0.172, P = 0.08).

CONCLUSION

Patients take most pain medication during the first postoperative week after adolescent ACLR, although patient and surgical variables had no notable influence on pill consumption.

LEVEL OF EVIDENCE

Level IV, case series.

Opioid-Prescribing Practices in Plastic Surgery: A Juxtaposition of Attendings and Trainees

BACKGROUND

The rates of opioid abuse and overdose in America have risen in parallel with the rates of opioid prescribing by physicians. As such, we sought to examine the prescribing practices among plastic surgery attendings and trainees to determine the need for more thorough education.

METHODS

A survey was distributed to all ACGME-accredited plastic surgery residency programs and included questions regarding opioid-prescribing practices and self-rated ability pertaining to opioid management. Trends in prescribing practices based on prescriber position were analyzed using cumulative odds ordinal logistic regression with proportional odds and Chi-squared tests for ordinal and nominal variables, respectively.

RESULTS

We received 78 responses with a wide geographical representation from plastic surgery residency programs: 59% of respondents were male and 39.7% female, 29.5% were attendings, 26.9% senior residents, 29.5% junior residents, and 14.1% interns. Compared with attendings, interns prescribe fewer pills (p < 0.05) and were significantly more likely to prescribe oxycodone (p < 0.03). Junior residents were 4.49 times more likely (p = 0.012) and senior residents 3.65 times more likely (p = 0.029) to prescribe additional opioids to avoid phone calls and follow-up visits. Interns and senior residents were significantly less comfortable than attendings in managing patients requesting additional opioids (p < 0.02).

CONCLUSIONS

The results of this survey demonstrate that knowledge deficits do exist among trainees, and that trainees are significantly less comfortable than their attending counterparts with opioid prescribing and patient management. Therefore, the implementation of a thorough postoperative pain management education in residency may be a cogent strategy in mitigating the opioid crisis.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Benchmarks of Duration and Magnitude of Opioid Consumption After Common Spinal Procedures: A Database Analysis of 47,823 Patients

STUDY DESIGN

A retrospective cohort study performed in a nationwide insurance claims database.

OBJECTIVE

This study aimed to examine duration and magnitude of postoperative opioid prescriptions following common spinal procedures.

SUMMARY OF BACKGROUND DATA

Postoperative opioid prescription practices vary widely among providers and procedures and standards of care are not well-established. Previous work does not adequately quantify both duration and magnitude of opioid prescription.

METHODS

Forty seven thousand eight hundred twenty three patients with record of any of four common spinal procedures in a nationwide insurance claims database were stratified by preoperative opioid use into three categories: "opioid naive," "sporadic user," or "chronic user," defined as 0, 1, or 2+ prescriptions filled in the 6 months preceding surgery. Those with record of subsequent surgery or readmission were excluded. Duration of opioid use was defined as the time between the index surgery and the last record of filling an opioid prescription. Magnitude of opioid use was defined as milligram morphine equivalents (MME) filled by 30 days post-op, converted to 5 mg oxycodone pills for interpretation.

RESULTS

Opioid naive patients were less likely than chronic opioid users to fill any opioid prescription after surgery (63-68% naive vs. 91-95% chronic, P < 0.001), and when they did, their prescriptions were smaller in magnitude (76-91 pills naive vs. 127-152 pills chronic). One year after surgery, 15% to 18% of opioid naive and 50% to 64% of chronic opioid users continued filling prescriptions.

CONCLUSION

Opioid naive patients use less postoperative opioids, and for a shorter period of time, than chronic users. This study serves as a normative benchmark for examining postoperative opioid use, which can assist providers in identifying patients with opioid dependence. Importantly, this work calls out the high risk of opioid exposure, as 15% to 18% of opioid naive patients continued filling opioid prescriptions 1 year after surgery.

LEVEL OF EVIDENCE

3.

Opioid Use in Children and Adolescents After Anterior Cruciate Ligament Repair

Opioid overdose is a leading cause of death from unintentional injury in the United States. When more opioids are prescribed than needed, leftover opioids may be misused if not properly disposed. The purpose of this study is to describe the opioid use of subjects (aged 13-21 years) after an anterior cruciate ligament (ACL) repair. After obtaining IRB approval, we obtained consent from 100 subjects (over an 8-month period) undergoing ACL reconstructions performed by five sports medicine surgeons. The mean age of enrolled subjects was 16 years, most were female (60%) and white (72%). While in the hospital, many subjects received the following: a regional anesthetic technique through a single shot femoral nerve block (50%); ketorolac (89%); and acetaminophen (84%). One week after surgery, we interviewed subjects to determine the amount of opioid used (36%) as compared to the amount prescribed.

Patient Satisfaction With Nonopioid Pain Management Following Arthroscopic Partial Meniscectomy and/or Chondroplasty

PURPOSE

To evaluate the efficacy of nonopioid pain medication related to patient satisfaction with postoperative pain and identify potential risk factors for decreased patient satisfaction with nonopioid pain medications.

METHODS

This was a prospective study conducted between January 2017 and April 2018 at a single institution. A power analysis was performed a priori, which determined an appropriate cohort size of 163 patients. Inclusion criteria were all patients older than age 18 who were undergoing a knee arthroscopy for a partial meniscectomy and/or chondroplasty. Patients were prescribed maximum-strength ibuprofen or acetaminophen and completed a preoperative and 2-week postoperative questionnaire to assess satisfaction with pain management.

RESULTS

Among the 163 patients enrolled in the study, the average age was 48.7 years (range 21-73 years); 74 (45%) were male and 89 (55%) were female. Overall, 81.6% (95% confidence interval 75.7% to 87.5%, P < .001) of patients reported satisfactory postoperative pain control without the use of opioids. Patients with a history of opioid use were found to be less likely to report adequate satisfaction with pain control than were patients who had no prior history of opioid use (relative risk 0.65, 95% confidence interval 0.38-1.12, P = .031).

CONCLUSIONS

Based on the findings of this study, 82% of patients who undergo arthroscopic partial meniscectomy and/or chondroplasty can achieve satisfactory pain control with nonopioid pain management.

LEVEL OF EVIDENCE

Prospective comparative study: Level II.

Benchmarks of Duration and Magnitude of Opioid Consumption After Total Hip and Knee Arthroplasty: A Database Analysis of 69,368 Patients

BACKGROUND

Opioid prescribing after orthopedic surgeries varies widely, and there is little consensus establishing proper standards of care. This retrospective cohort study examines opioid prescribing trends following total hip (THA) and knee (TKA) arthroplasty and evaluates preoperative opioid use as a predictor of duration and magnitude of postoperative opioid use.

METHODS

Patients who underwent THA or TKA in a nationwide insurance database were stratified by preoperative opioid use. Naive, sporadic, and chronic users were defined as 0, 1, or 2+ prescriptions filled 6 months before surgery. Patients were excluded for readmission or subsequent surgery. Duration of opioid use was defined as time between the procedure and the last opioid prescription record, and magnitude of opioid use was defined as quantity of pills filled by 30 days postop.

RESULTS

Naive patients were less likely than chronic users to fill any opioid prescription after surgery (THA: 61.5% naive vs 90.4% chronic, TKA: 72.0% naive vs 95.9% chronic), and they obtained fewer pills (THA: 73 pills naive vs 126 pills chronic, TKA: 86 pills naive vs 126 pills chronic, 5-mg oxycodone equivalent). Between 10% (THA) and 13% (TKA) of naive and between 47% (THA) and 62% (TKA) of chronic users continued opioid use at 1 year postop.

CONCLUSION

Chronic users obtain more opioids postoperatively and continue filling prescriptions for longer than naive patients. This work benchmarks norms regarding opioid use and furthermore these data highlight the powerful effect of opioid exposure during surgery as 10%-13% of naive patients continued opioids at 1 year postop.

The Utility of Oral Nonsteroidal Anti-inflammatory Drugs Compared With Standard Opioids Following Arthroscopic Meniscectomy: A Prospective Observational Study

PURPOSE

To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids following arthroscopic partial meniscectomy.

METHODS

This was a single-center, prospective, nonrandomized, comparative observational study. Patients ages 18 to 65 years who were indicated for arthroscopic meniscectomy were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) ibuprofen (600 mg every 6-8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg as needed for breakthrough pain) or (2) 30 to 40 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 8 hours, 24 hours, 48 hours, and 1 week after surgery, which included medication usage, visual analog scale pain score, incidence of adverse events, and patient satisfaction.

RESULTS

Sixty-eight patients with mean age 51.2 years (±10.4 years) were enrolled between October 2016 and February 2017. Enrollment in the opioid group continued until 30 patients were enrolled in the NSAID group, and at final analysis there were 28 patients in the NSAID group and 40 in the opioid group. There were no significant differences in sex, visual analog scale pain score, or patient satisfaction between the 2 groups at any time point. Patients in the opioid group had a significantly higher mean opioid consumption on postoperative day 1 (1.1 vs 0.5 tablets, P < .03) and postoperative days 3 to 7 (2.6 vs 0.5 tablets, P < .02) compared with NSAID group patients. There was a trend toward greater total (1 week) opioid usage (4.7 vs 2.0 tablets) in the opioid group; however, this was not statistically significant (P < .08). Fifty-three percent of opioid group patients independently chose to forego their opioid medication for an over-the-counter NSAID and/or acetaminophen instead. No patients requested a medication refill.

CONCLUSIONS

We found no significant difference in pain control, satisfaction, and total 1-week opioid use between patients prescribed NSAIDs with opioids and those prescribed opioids alone. All patients used only limited amounts of opioids to control postoperative pain, suggesting we are currently overprescribing opioids after arthroscopic partial meniscectomy.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Opioid Prescribing Practices of Orthopaedic Surgeons: Results of a National Survey

INTRODUCTION

Opioids are widely used after orthopaedic procedures. Nonmedical opioid use is a growing public health issue.

METHODS

An anonymous online survey was distributed by e-mail to the orthopaedic societies of all 50 states and several large private practices to assess practicing orthopaedic surgeons' opioid prescribing practices.

RESULTS

A total of 555 orthopaedic surgeons practicing in 37 states responded. The most commonly prescribed opioid for both teenagers and adults was hydrocodone/acetaminophen. Of note, 42.3% reported that a patient they have prescribed opioids for developed an opioid dependency, whereas 35.3% do not believe that opioid use is a problem in their practice. Of note, 30.3% reported prescribing refills, and factors significantly associated with increased prescribing of refills included a greater number of years in practice (P < 0.001) and practicing in a suburban rather than an urban or rural environment (P = 0.03).

CONCLUSION

Orthopaedic surgeons rarely prescribe any refills, tend to prescribe less opioids to teenagers than adults, and prescribe fairly uniformly for patients who are treated nonsurgically or undergo minor or arthroscopic surgery. They exhibit considerable variation in prescribing for fractures and major procedures.

Post-surgical opioid prescribing patterns and risk factors for additional opioid prescriptions within one year after non-emergent colorectal surgery

BACKGROUND

National opioid concerns resulted in review of prescribing patterns following colorectal surgery.

METHODS

This retrospective cohort study examined prescribing patterns in elective colorectal surgery at a tertiary academic medical center from January 2012 through December 2014.

RESULTS

Forty percent of 4286 patients received additional opioid prescriptions within the year following colorectal surgery. Multivariable analysis demonstrated that a pre-operative opioid prescriptions within 1 year of surgery (OR 2.91; 95% CI, 1.83-4.60), increasing operative time (OR 1.02; 95% CI, 1.00-1.04), or complications (OR 2.18; 95% CI, 1.38-3.43) was associated with additional opioid prescriptions. The median opioid prescription upon discharge was 225 mg morphine milligram equivalents. Discharge opioid amount was not a risk factor.

CONCLUSIONS

Additional opioid prescriptions after surgery occurred in 40% of patients. Pre-operative prescriptions, increasing operative time and complications were associated with additional opioid prescriptions while opioid amount at discharge was not a risk factor.

Opioid Prescription and Usage in Adolescents Undergoing Orthopaedic Surgery in the United States: A Systematic Review

BACKGROUND

The proper use of opioid analgesia for postoperative pain management is controversial. While opioids are considered the standard of care for multimodal postoperative pain modulation in the United States, there is a lack of established protocols for prescribing opioids in adolescents undergoing outpatient orthopaedic surgery. The objective of this review was to identify and report on current literature on opioid prescription for pain management in adolescents undergoing all procedures, as well as in adults undergoing outpatient orthopaedic surgery.

METHODS

A comprehensive literature search using PRISMA guidelines was performed to identify all articles relevant to opioid use in adolescents for postoperative pain and in adults following outpatient orthopaedic procedures.

RESULTS

A total of 4,446 results were identified from databases and relevant journal web sites. Of these, 9 articles were selected that fit the criteria for review. Five studies discussed the dosage and type of opioids prescribed in adolescent populations, and 4 quantified patient self-administration in adult populations.

CONCLUSIONS

Adolescent opioid pain management following outpatient orthopaedic surgery is not documented. Current recommendations for opioid prescription in adolescents lack support and are primarily based on adult dosages. Adult studies suggest that opioid medications may be overprescribed following outpatient orthopaedic surgery. These results clearly indicate that there is a pressing need for quantitative research on pain management following outpatient orthopaedic surgery in the adolescent population in the United States.

CLINICAL RELEVANCE

There appear to be no studies on self-administered opioid pain medication following orthopaedic surgery in an adolescent population, suggesting that there is no objective basis for the current prescription recommendations.

Patterns of Narcotic Prescribing by Orthopedic Surgeons for Medicare Patients

In recent years, narcotics have been subject to increased regulation and monitoring because of their side effects and potential for misuse. Currently, variation in prescribing patterns of narcotics among orthopedic surgeons is unknown. The Medicare Part D claims database was used to identify orthopedic surgeons who prescribed at least one schedule II or III narcotic during 2014. The median duration of a narcotic prescription was 8.2 days. The median prescription duration was shortest for hand surgeons (5.6 days) and longest for spine surgeons (12.6 days). Orthopedic surgeons in New York (10.1 days) provided the most narcotics per prescription, with physicians in Vermont (6.2 days) providing the least. Substantial variation exists in narcotic prescribing patterns for orthopedic surgeons at the individual, subspecialty, and statewide levels. With public health focus on reducing narcotics abuse, physician stewardship of these medications will become increasingly relevant.

Excess Opioid Medication and Variation in Prescribing Patterns Following Common Orthopaedic Procedures

BACKGROUND

Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. Understanding prescribing habits and patient utilization of these medications following a surgical procedure is critical to establishing appropriate prescribing protocols that effectively control pain while minimizing unused opioid distribution. We evaluated prescribing habits and patient utilization following elective orthopaedic surgical procedures to identify ways of improving postoperative opioid-prescribing practices.

METHODS

We performed a review of prescribing data of 1,199 procedures and gathered telephone survey results from 557 patients to determine the number of opioid pills prescribed postoperatively and the number of unused pills. The data were collected from adult patients who underwent 1 of the 5 most common elective orthopaedic procedures at our institution in fiscal year 2015: total hip arthroplasty, total knee arthroplasty, endoscopic carpal tunnel release, arthroscopic rotator cuff repair, or lumbar decompression. We converted all dosages to opioid equivalents of oxycodone 5 mg and performed analyses of prescribing patterns, patient utilization, and patient disposal of unused opioids.

RESULTS

Prescribing patterns following the 5 orthopaedic procedures showed wide variation. The median numbers of oxycodone 5-mg equivalent opioid pills prescribed upon discharge were 90 pills (range, 20 to 330 pills) for total hip arthroplasty, 90 pills (range, 10 to 200 pills) for total knee arthroplasty, 20 pills (range, 0 to 168 pills) for endoscopic carpal tunnel release, 80 pills (range, 18 to 100 pills) for arthroscopic rotator cuff repair, and 80 pills (range, 10 to 270 pills) for lumbar decompression. Thirty-seven percent of patients overall requested and received at least 1 refill. The mean number of total pills prescribed (and standard deviation) including refills was 113.6 ± 75.7 for total hip arthroplasty, 176.4 ± 108.0 for total knee arthroplasty, 24.3 ± 29.0 for carpal tunnel release, 98.2 ± 59.6 for rotator cuff repair, and 107.4 ± 64.4 for lumbar decompression. Participants reported unused opioid medication in 61% of cases. During the study year, >43,000 unused opioid pills were prescribed. Forty-one percent of patients reported appropriate disposal of unused opioid pills.

CONCLUSIONS

Prescribing patterns vary widely, and a large amount of opioid medications remains unused following elective orthopaedic surgical procedures. Effective prescribing protocols are needed to limit this source of potential abuse and opioid diversion within the community.

Managing Opioid Addiction Risk in Plastic Surgery during the Perioperative Period

Opioid addiction is a public health crisis that affects all areas of medicine. Large numbers of the population across all racial and economic demographics misuse prescription opioids and use illicit opioids. The current understanding is that opioid misuse is a disease that requires treatment, and is not an issue of choice or character. Use of opioid medication is a necessary part of postoperative analgesia, but many physicians are unsure of how to do this safely given the risk of patients developing an opioid misuse disorder. This review gives an update of the current state of the opioid crisis, explains how current surgeons' prescribing practices are contributing to it, and gives recommendations on how to use opioid medication safely in the perioperative period.