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

Adherence to legislation limiting opioid prescription duration following musculoskeletal injury

OBJECTIVES

North Carolina had implemented legislation (Strengthen Opioid Misuse Prevention (STOP) Act) limiting opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain. This study aimed to identify patient, prescriber, and facility characteristics associated with STOP Act adherence for patients with acute or post-surgical musculoskeletal (MSK) conditions.

DESIGN

A three-level hierarchical logistic regression model was used to predict odds of adherence with STOP Act duration limits, accounting for fixed and random effects at the patient, prescriber, and facility levels.

SETTING

A large healthcare system in North Carolina.

PATIENTS AND PARTICIPANTS

Patients (N = 6,849) presenting from 2018 to 2020 with a diagnosis of an acute MSK injury.

INTERVENTIONS

The STOP Act limited the duration of opioid prescriptions in North Carolina.

MAIN OUTCOME MEASURE

Prescriptions adhering to the STOP Act duration limits of 5 days (nonoperative) or 7 days (operative) were the primary outcome.

RESULTS

Opioids were compliant with STOP Act duration limits in 69.3 percent of encounters, with 33 percent of variation accounted for by clinician and 29 percent by facility. Patients prescribed >1 opioid (odds ratio (OR) 0.46, 95 percent confidence interval (CI): 0.36, 0.58) had reduced odds of a compliant prescription; surgical patients had increased odds of a compliant prescription (outpatient surgery: OR 5.89, 95 percent CI: 2.43-14.29; inpatient surgery: OR 7.71, 95 percent CI: 3.04-19.56). Primary care sports medicine clinicians adhered to legislation less frequently than orthopedic surgeons (OR 0.38, 95 percent CI: 0.15, 0.97).

CONCLUSIONS

Most prescriptions adhered to STOP Act legislation. Tailored interventions to improve adherence among targeted groups of prescribers, eg, those treating nonoperative injuries and sport medicine clinicians, could be useful.

Attitudes and Practices Surrounding Opioid Prescriptions following Open Reduction Internal Fixation of Distal Radius and Ankle Fractures: A Survey of the Canadian Orthopaedic Association Membership

Background

The past two decades have seen a significant increase in consequences associated with nonmedical misuse of prescription opioids, such as addiction and unintentional overdose deaths. This study aimed to use an electronic survey to assess attitudes and opioid-prescribing practices of Canadian orthopaedic surgeons and trainees following open reduction internal fixation (ORIF) of distal radius and ankle fractures. This study was the first to assess these factors following ORIF of distal radius and ankle fractures using a survey design.

Methods

A 40-item survey was developed focusing on four themes: respondent demographics, opioid-prescribing practice, patients with substance use disorders, and drug diversion. The survey was distributed among members of the Canadian Orthopaedic Association. Descriptive statistics were used to summarize respondent demographics and outcomes of interest. A Chi-square test was used to determine if proportion of opioid prescriptions between attending surgeons and surgeons in training was equal.

Results

191 surveys were completed. Most respondents prescribed 10-40 tabs of immediate-release opioids, though this number varied considerably. While most respondents believed patients consumed only 40-80% of the prescribed opioids (73.6%), only 28.7% of respondents counselled patients on safe storage/disposal of leftover opioids. 30.5% of respondents felt confident in their knowledge of opioid use and mechanisms of addiction. Most respondents desired further education on topics such as procedure-based opioid-prescribing protocols (74.2%), alternative pain management strategies (69.7%), and mechanisms of opioid addiction (49.0%).

Conclusions

The principle finding of this study is the lack of a standardized approach to postoperative prescribing in distal radius and ankle fractures, illustrated by the wide range in number of opioids prescribed by Canadian orthopaedic surgeons. Our data suggest a trend towards overprescription among respondents following distal radius and ankle ORIF. Future studies should aim to rationalize interventions targeted at reducing postoperative opioid prescribing for common orthopaedic trauma procedures.

A Review of Federal and Statewide Guidelines and Their Effects on Orthopedics

In the past three decades, the use of opioids has risen tremendously. Pain was named the "fifth patient vital sign" in the 1990s, and from that point, opioid usage has continued to grow throughout the 2010s leading to its recognition as a crisis. The United States is responsible for 80% of the global opioid usage while only accounting for less than 5% of the global population. Previously opioids were mostly used to treat acute pain, however, opioids have been most recently used to manage chronic pain as well. The opioid crisis has presented new challenges in treating pain while preventing the abuse of these medications in a system that lacks standardization of treatment guidelines across the United States. Therefore, the authors of this review examine the current national recommendations to help manage the ongoing opioid crisis and explore how they may impact orthopedic patient care.

Strategies to prevent long-term opioid use following trauma: a Canadian practice survey

PURPOSE

To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed.

METHODS

We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021.

RESULTS

Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies.

CONCLUSIONS

Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.

Unused opioid prescription prevalence after pediatric ambulatory surgery: a survey study

Background

Surgery is a risk factor for opioid initiation, persistent use, and subsequent misuse in pediatric patients. The objective of this study was to assess the rate of postoperative opioid prescribing and extent of unused opioid prescriptions on the first postoperative day after pediatric ambulatory surgery.

Methods

A telephone survey was administered on postoperative day 1 (POD1) to guardians of all pediatric patients who underwent ambulatory surgery at a single medical center. Participants were asked whether postoperative opioids were prescribed, and, if yes, whether they were currently taking them. Multivariable logistic regression was used to assess factors associated with postoperative opioid prescribing and unused opioids on POD1.

Results

Of 1344 pediatric patients who underwent ambulatory surgical procedures, 849 (63.1%) guardians responded to the survey. 275 (32.4%) were prescribed postoperative opioids, and 164 (59.6%) reported not taking opioids on POD1. The highest rates of unused opioid prescriptions were from orthopedic and plastic surgery services (28% and 29%, respectively). Governmental insurance status predicted having unused opioids (OR 0.59, CI 0.35–0.97).

Conclusions

Unused opioid prescriptions were prevalent in this pediatric ambulatory surgical population. Opportunities remain to streamline opioid prescribing in pediatric patients undergoing ambulatory surgical procedures.

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.

Opioid use for a first-incident upper extremity fracture in 220,440 patients without recent prior use in Ontario, Canada: a retrospective cohort study

To describe opioid use for a first upper extremity fracture in a cohort of patients who did not have recent opioid use.

Design

Descriptive epidemiological study.

Setting

Emergency Department, Hospital.

Patients/Participants

We obtained health administrative data records of adults presenting with a first adult upper extremity fracture from 2013 to 2017 in Ontario, Canada. We excluded patients with previous fractures, opioid prescription in the past 6 months or hospitalization >5 days after the fracture.

Intervention

Opioid prescription.

Main Outcome Measurements

We identified the proportion of patients filling an opioid prescription within 7 days of fracture. We described this based on different upper extremity fractures (ICD-10), Demographics (age, sex, rurality), comorbidity (Charlson Comorbidity Index, Rheumatoid arthritis, Diabetes), season of injury, and social marginalization (Ontario Marginalization Index-a data algorithm that combines a wide range of demographic indicators into 4 distinct dimensions of marginalization). We considered statistical differences (P< .01) that reached a standardized mean difference of 10% as being clinically important (standardized mean difference [SMD] ≥ 0.1).

Results

From 220,440 patients with a first upper extremity fracture (50% female, mean age 50), opioids were used by 34% of cases overall (32% in males, 36% in females, P< .001, SMD ≥ 0.1). Use varied by body region, with those with multiple or proximal fractures having the highest use: multiple shoulder 64%, multiple regions 62%, shoulder 62%, elbow 38%, wrist 31%, and hand 21%; and was higher in patients who had a nerve/tendon injury or hospitalization (P< .01, SMD ≥ 0.1). Social marginalization, comorbidity, and season of injury had clinically insignificant effects on opioid use.

Conclusions

More than one-third of patients who are recent-non-users will fill an opioid prescription within 7 days of a first upper extremity fracture, with usage highly influenced by fracture characteristics.Level of Evidence: Level II.

Effects of hypnosis versus enhanced standard of care on postoperative opioid use after total knee arthroplasty: the HYPNO-TKA randomized clinical trial

BACKGROUND

Hypnosis decreases perioperative pain and has opioid-sparing potential but has not been rigorously studied in knee arthroplasty. This trial investigates the impact of perioperative hypnosis on inpatient opioid use following total knee arthroplasty.

METHODS

This prospective randomized controlled trial was conducted at a single academic medical center. The hypnosis arm underwent a scripted 10 min hypnosis session prior to surgery and had access to the recorded script. The control arm received hypnosis education only. The primary outcome was opioid use in milligram oral morphine equivalents per 24 hours during hospital admission. A secondary analysis was performed for patients taking opioids preoperatively.

RESULTS

64 primary knee arthroplasty patients were randomized 1:1 to hypnosis (n=31) versus control (n=33) and included in the intent-to-treat analysis. The mean (SD) postoperative opioid use in oral morphine equivalents per 24 hours was 70.5 (48.4) in the hypnosis versus 90.7 (74.4) in the control arm, a difference that was not statistically significant (difference -20.1; 95% CI -51.8 to 11.4; p=0.20). In the subgroup analysis of the opioid-experienced patients, there was a 54% daily reduction in opioid use in the hypnosis group (82.4 (56.2) vs 179.1 (74.5) difference of -96.7; 95% CI -164.4 to -29.0; p=<0.01), equivalent to sparing 65 mg of oxycodone per day.

CONCLUSION

Perioperative hypnosis significantly reduced inpatient opioid use among opioid-experienced patients only. A larger study examining these findings is warranted.

TRIAL REGISTRATION NUMBER

NCT03308071.

What is the adult experience of Perthes' disease? : initial findings from an international web-based survey

AIMS

Perthes' disease is an uncommon hip disorder with limited data on the long-term outcomes in adulthood. We partnered with community-based foundations and utilized web-based survey methodology to develop the Adult Perthes Survey, which includes demographics, childhood and adult Perthes' disease history, the University of California Los Angeles (UCLA) Activity Scale item, Short Form-36, the Hip disability and Osteoarthritis Outcome Score, and a body pain diagram. Here we investigate the following questions: 1) what is the feasibility of obtaining > 1,000 survey responses from adults who had Perthes' disease using a web-based platform?; and 2) what are the baseline characteristics and demographic composition of our sample?

METHODS

The survey link was available publicly for 15 months and advertised among support groups. Of 1,505 participants who attempted the Adult Perthes survey, 1,182 completed it with a median timeframe of 11 minutes (IQR 8.633 to 14.72). Participants who dropped out were similar to those who completed the survey on several fixed variables. Participants represented 45 countries including the USA (n = 570; 48%), UK (n = 295; 25%), Australia (n = 133; 11%), and Canada (n = 46; 4%). Of the 1,182 respondents, 58% were female and the mean age was 39 years (SD 12.6).

RESULTS

Ages at onset of Perthes' disease were < six years (n = 512; 43%), six to seven years (n = 321; 27%), eight to 11 years (n = 261; 22%), and > 11 years (n = 76; 6%), similar to the known age distribution of Perthes' disease. During childhood, 40% (n = 476) of respondents had at least one surgery. Bracing, weightbearing restriction, and absence of any treatment varied significantly between USA and non-USA respondents (p < 0.001, p = 0.002, and p < 0.001, respectively). As adults, 22% (n = 261) had at least one total hip arthroplasty, and 30% (n = 347) had any type of surgery; both more commonly reported among women (p = 0.002).

CONCLUSION

While there are limitations due to self-sampling, our study shows the feasibility of obtaining a large set of patient-reported data from adults who had childhood Perthes' from multiple countries. Cite this article: Bone Jt Open 2022;3(5):404-414.

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.

A focus on the future of opioid prescribing: implementation of a virtual opioid and pain management module for medical students

BACKGROUND

The United States opioid epidemic is a devastating public health crisis fueled in part by physician prescribing. While the next generation of prescribers is crucial to the trajectory of the epidemic, medical school curricula designated to prepare students for opioid prescribing (OP) and pain management is often underdeveloped. In response to this deficit, we aimed to investigate the impact of an online opioid and pain management (OPM) educational intervention on fourth-year medical student knowledge, attitudes, and perceived competence.

METHODS

Graduating students completing their final year of medical education at Sidney Kimmel Medical College of Thomas Jefferson University were sent an e-mail invitation to complete a virtual OPM module. The module consisted of eight interactive patient cases that introduced topics through a case-based learning system, challenging students to make decisions and answer knowledge questions about the patient care process. An identical pre- and posttest were built into the module to measure general and case-specific learning objectives, with responses subsequently analyzed using the Wilcoxon matched-pairs signed-rank test.

RESULTS

Forty-three students (19% response rate) completed the module. All median posttest responses ranked significantly higher than paired median pretest responses (p <  0.05). Comparing the paired overall student baseline score to module completion, median posttest ranks (Mdn = 206, IQR = 25) were significantly higher than median pretest ranks (Mdn = 150, IQR = 24) (p <  0.001). Regarding paired median Perceived Competence Scale metrics specifically, perceived student confidence, capability, and ability in opioid management increased from "disagree" (2) to "agree" (4) (p <  0.001), and student ability to meet the challenge of opioid management increased from "neither agree nor disagree" (3) to "agree" (4) (p <  0.001). Additionally, while 77% of students reported receiving OP training in medical school, 21% reported no history of prior training.

CONCLUSION

Implementation of a virtual, interactive module with clinical context is an effective framework for improving the OPM knowledge, attitudes, and perceived competence of fourth-year medical students. This type of intervention may be an important method for standardizing and augmenting the education of future prescribers across multiple institutions.

Opioid-prescribing patterns among shoulder and elbow surgeons: considerations for future prescription guidelines

BACKGROUND

Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers.

METHODS

In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents' prescribing practices, and methods of patient counseling regarding opioid use and disposal.

RESULTS

A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient's symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines.

DISCUSSION

To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.

Appropriate Opioid Use After Spine Surgery: Psychobehavioral Barriers and Patient Knowledge

OBJECTIVE

To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors.

METHODS

We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α = 0.05).

RESULTS

Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95).

CONCLUSIONS

Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use.

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.

Opioid Prescriptions by Orthopaedic Surgeons in a Medicare Population: Recent Trends, Potential Complications, and Characteristics of High Prescribers

INTRODUCTION

Orthopaedic surgeons prescribe an estimated 7.7% of all US opioid prescriptions, and understanding prescribing patterns is important to curtail the inappropriate dispensing of these drugs. The purpose of this study was to characterize recent trends in opioid prescribing patterns by orthopaedic surgeons within a Medicare population and to identify demographical characteristics associated with the highest prescribers.

METHODS

This study used Medicare Part D beneficiary prescription between 2013 and 2016. The number of prescriptions written per orthopaedic surgeon, prescriptions received by each beneficiary, and the length of each prescription were compared across years. Top prescribers were identified and compared with the remainder of prescribers to identify differences in sex, professional degree, and geographic regions.

RESULTS

Between 2013 and 2016, an average of 24,100 unique orthopaedic prescribers were identified. There was a decrease in the average number of prescriptions written per year from 157 to 148 and per beneficiary from 2.1 to 1.8 from 2013 to 2016, respectively. The most commonly prescribed opioids were hydrocodone/acetaminophen (47.1% of all opioids prescribed) and oxycodone/acetaminophen (17.5%). The total number of opioid prescriptions decreased by 372,045, and nonopioid pain medications increased by 269,917 between 2013 and 2016. Orthopaedic surgeons were more likely to have a high total opioid prescription count if they were male, lived in the south, and had an osteopathic degree (P < 0.001 for all).

DISCUSSION

Orthopaedic surgeons prescribe an estimated 7.7% of all US opioid prescriptions; however, in recent years, there has been a decrease in the number of prescriptions written per surgeon, per beneficiary, total opioid prescriptions, and an increase in total nonopioid prescriptions. These changes may reflect an increase in public awareness of the opioid epidemic and subtle changes in physician behavior. Differences in opioid prescription volume by sex, professional degree, and region also illustrate a lack of consensus on opioid prescription guidelines in orthopaedic surgery.

A Simple, Personalized Opioid Stratification Pathway Dramatically Reduces Opioid Utilization

Orthopaedic surgeons account for the largest proportion of opioid prescriptions in the United States among surgical specialties. In total joint arthroplasty, increased opioid use has been associated with poorer clinical and functional outcomes. Despite an abundance of literature on opioid mitigation strategies, most fail to provide personalized prescriptions. Typically, most protocols prescribe the same opioid regimen regardless of patient factors or the extent of the planned procedure. We present a simple opioid stratification pathway that can be used by physicians and office staff as they prepare patients for arthroplasty. We have found this to be easy to implement, effective, and sustainable at a tertiary academic institution and allows for iterative improvements over time.

Assessment of Unused Opioids Following Ambulatory Surgery

Background

Surgery is a risk factor for opioid initiation and subsequent abuse. Discharge opioid prescription patterns after surgery are often varied and not evidence based, which may lead to unnecessary prescription of opioids. We aimed to assess opioid prescribing and unused opioid prescriptions in ambulatory surgery patients at our academic hospital.

Methods

We conducted a retrospective observational study based on phone survey and electronic medical records. Adult patients who underwent ambulatory surgery at our large, multisite, tertiary-care hospital system were asked whether they were using the opioids that were prescribed at discharge. Our main outcomes were opioid prescription (defined as being prescribed an opioid on discharge) and unused opioid prescription (defined as being prescribed an opioid but not taking any opioids on postoperative day 1). We evaluated predictors of opioid prescription and unused opioid prescription through univariable and multivariable analyses. We also stratified outcomes by surgical service.

Results

Of 4248 adult patients who underwent ambulatory surgical procedures, 3279 (77.2%) responded to the survey. Of all responders, 2146 (65.4%) were prescribed postoperative opioids, and 1240 (57.8%) reported not taking them on postoperative day 1. The highest rates of unused opioid prescriptions were for patients whose primary service were orthopedic surgery (65%) and plastic surgery (62%).

Discussion

Opioid prescribing and unused opioid prescriptions are prevalent in our hospital’s ambulatory surgical population. Patients undergoing selected ambulatory surgical procedures may not require as much opioid as is currently being prescribed.

Proper Disposal of Prescription Opioids in Southwest Virginia: Assessment of Patient, Physician, and Medical Student Beliefs and Practices

CONTEXT

Southwestern Virginia demonstrates the highest regional mortality rate from prescription opioid overdoses. Nationally, 65% of patients misusing opioid medications received them from friends and family, underscoring the need for effective disposal of unused narcotics.

OBJECTIVES

(1) To understand patient, provider, and medical student beliefs and misconceptions regarding proper methods of opioid disposal; (2) to characterize discrepancies that exist between patient self-reported habits and medical student/provider perceptions of opioid usage, disposal, and diversion.

DESIGN

Descriptive, cross-sectional, observational study.

SETTING

Large, nonprofit health care organization and allopathic medical school in Southwestern Virginia.

PARTICIPANTS

All ambulatory patients 18 years or older presenting for elective consultation at health system orthopedics department; all institutionally employed physicians with active system e-mail addresses; and all current students at the associated medical school.

MAIN OUTCOMES/MEASURES

Patients: The number who had received information regarding proper methods of opioid disposal, intended disposal method, methods of disposal considered appropriate, comfort level with opioid disposal, and demographic data. Physicians and Medical Students: The number who had received instruction regarding proper methods of opioid disposal, acceptable means of opioid disposal, most appropriate disposal method, disposal method most likely to be employed by patients, practice profile/prescribing data, and medical school year.

RESULTS

In total, 64% of patients (n = 255/750) had never received instruction from a physician regarding opioid disposal; 56% of physicians (n = 212/732) and 78% (n = 80/171) of medical students indicated that they never received formal instruction regarding methods of disposal. The majority of physicians believed that their patients are most likely to use in-home methods of disposal or store prescription medications for future use; 61% of patients indicated a preference for accessible disposal facilities.

CONCLUSIONS

The discrepancy between patient and physician responses highlights a lack of communication regarding disposal of unused opioid medications and is a target for future intervention.

New Long-Term Opioid Prescription-Filling Behavior Arising in the 15 Months After Orthopaedic Surgery

BACKGROUND

The opioid crisis is a well-known public health issue. The risk of new long-term opioid prescription-filling behavior has been investigated after certain spinal procedures and total knee and hip arthroplasty. However, this has not been examined after many other common orthopaedic procedures. The purpose of this study was to determine the rates of long-term opioid prescription-filling behavior after common orthopaedic surgical procedures in patients who were not taking opioids preoperatively.

METHODS

This study utilized the Virginia All-Payer Claims Database (APCD), an insurance claims database with data from 3.7 to 4 million patients per year. Patients who underwent orthopaedic procedures and who had not filled an opioid prescription in the time period from 2 weeks to 1 year preceding the surgical procedure were selected for evaluation in our study. The percentage of these patients who then filled at least 10 prescriptions or a 120-day supply of opioids in the time period from 90 to 455 days following the surgical procedure was calculated for the 50 most commonly billed orthopaedic surgical procedures.

RESULTS

The rate of long-term opioid prescription-filling behavior in patients who were not taking opioids preoperatively for the 50 most common orthopaedic procedures was 5.3% (95% confidence interval, 5.1% to 5.5%). The highest rates were observed after spinal procedures. The lowest rates were seen after anterior cruciate ligament (ACL) reconstruction. Revision surgical procedures were found to have a significantly higher rate than primary procedures (p < 0.05). The rate was also related to increasing case complexity.

CONCLUSIONS

New long-term opioid prescription-filling behavior is common after orthopaedic surgical procedures in patients who were not taking opioids preoperatively. Risk factors include spine surgery, revision surgery, and cases with increased complexity. Orthopaedic surgeons need to be aware of this risk.

LEVEL OF EVIDENCE

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

A Goal-directed Quality Improvement Initiative to Reduce Opioid Prescriptions After Orthopaedic Procedures

Orthopaedic surgeons are increasingly aware of deleterious effects of the opioid epidemic and the association between overprescription and diversion toward nonmedical opioid use or substance abuse. Opiate prescriptions at the time of hospital discharge have been identified as target for intervention. This study describes the successful outcome of a goal-directed intervention aimed at decreasing opioid overprescription by providing routine feedback to providers regarding their prescribing patterns.