Doctor-Shopping Common After Orthopedic Trauma

Jenni Laidman

August 19, 2014

After orthopedic trauma surgery, 1 in 5 patients fill narcotic prescriptions from more than 1 physician. Overall, those patients filled 3 times more prescriptions, took nearly twice the daily dose, and took the narcotics 4 times longer than patients who were not physician-shoppers, according to a study published in the August issue of the Journal of Bone and Joint Surgery.

On average, the patients who physician-shopped had less education than those who did not, and they were more likely to have received 3 or more prescriptions for narcotics in the 3 months before their trauma surgery, the researchers found.

Mining the state's narcotic substance abuse monitoring database, Brent J. Morris, MD, who was at the time of the study a surgical resident at Vanderbilt University Medical Center, and colleagues found that patients who physician-shopped received an average of 7 narcotic prescriptions compared with 2 prescriptions for those who did not physician-shop (ranges, 4 - 9 and 2 - 4, respectively; P < .001). They continued taking the narcotics for an average of 110 days compared with 28 days for other patients (ranges, 77 - 143 and 28 - 112; P < .001), and they took a higher morphine-equivalent dose of drugs per day than nonshoppers (43 mg [range, 21 - 65 mg] vs 26 mg [range, 16 - 40 mg]; P = .002).

The prospective cohort study included 130 patients between the ages of 18 and 65 years who were admitted to a level 1 trauma center through the hospital emergency department for a single traumatic injury requiring surgery in 2011. To avoid confounding factors, the researchers excluded patients with multiple traumatic injuries and those with postoperative complications. They also excluded people whose primary residence was out of state or those for whom data were incomplete. The study looked at narcotic prescriptions for each patient beginning 3 months before surgery and ending when the patient's treating surgeon wrote the patient's last prescription.

The largest determinant of physician-shopping was the preoperative use of narcotics. Patients who filled narcotics prescriptions within 3 months of surgery were 4.5 times more likely to see multiple physicians for prescriptions after surgery (95% confidence interval, 2.9 - 7.0; P < .001). Education level was next: Trauma patients with a high school education or less were 3.2 times more likely to seek multiple prescriptions than those with more education (95% confidence interval, 1.3 - 8.1; P = .02).

The shoppers and nonshoppers did not differ from one another in terms of age, sex, race, injury type, distance of patient's home from hospital, tobacco use, psychiatric history, or comorbidities.

"I think what the study tells us is there is a subgroup of patients you need to be a little more vigilant on, that they may be taking more drugs than you think they're taking," Doug Lundy, MD, a spokesperson for the American Academy of Orthopedic Surgeons, who is from Resurgens Orthopaedics in Atlanta, Georgia, told Medscape Medical News. But the bottom line remains: "We have to treat these patients' pain, and treat it responsibly. We want them to understand the seriousness of the drugs they're taking and be aware and prevent the risk of overdose.

"But whether they're abusing or have a pain syndrome, that doesn't matter if their tibia is broken and sticking through the skin. You have to treat the pain," Dr. Lundy said. "When we realize somebody has addiction issues, we get them in with pain management specialists."

The authors caution that the data may not be representative of patients with multiple traumas. "Furthermore, we were unable to determine why patients were being treated with narcotics preoperatively and why they sought additional providers and additional narcotic prescriptions postoperatively. There may be additional injuries or conditions requiring narcotic prescriptions of which we were not aware in addition to the operative orthopaedic injury," the authors write.

Only 1 other study has looked at the relationship between physician-shopping and postoperative narcotic use for orthopedic trauma, the authors report. That study, conducted in Utah, found that patients who filled more than 1 opiate prescription before their injury were 6 times more likely to use opiates longer than 12 weeks than other patients, and 3.5 times more likely to obtain opiates from a provider other than their surgeon.

"Orthopaedic surgeons must prescribe narcotic medications in the postoperative period with great care and vigilance to minimize the risk of abuse, dependence, and narcotic-related adverse events in their patients," the authors conclude.

One coauthor has reported working as an educational consultant outside the submitted work for Smith and Nephew. The other authors and Dr. Lundy have disclosed no relevant financial relationships.

J Bone Joint Surg Am. 2014;96:1257-1262. Abstract

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