Notable Variability in Opioid-Prescribing Practices After Common Orthopaedic Procedures

Sophia A. Traven, MD; Daniel L. Brinton, PhD; Shane K. Woolf, MD; Lee R. Leddy, MD; Michael B. Gottschalk, MD; Harris S. Slone, MD

Disclosures

J Am Acad Orthop Surg. 2021;29(5):219-226. 

In This Article

Discussion

This study demonstrates notable inter- and intra-regional variabilities in opioid prescribing practices across the United States for common orthopaedic procedures. Furthermore, the variability between the initial and 90-day prescriptions was reflected by the number of patients who were prescribed refills for a given procedure. Although patients undergoing soft-tissue–only procedures required the fewest refills, patients undergoing total joint arthroplasty required the most. Because physician prescribing practices are increasingly scrutinized, high-quality evidence and thoughtful data analysis is critical to ensure optimal quality of care.

Interestingly, these data highlight a dichotomy between opioids prescribed and opioid-related deaths as reported by the CDC. The CDC's data observed that deaths from heroin and synthetic opioids in 2015 were highest in the Northeast, followed by the Midwest, South, and West.[7,8] In the present study, it should be noted the Northeast prescribed OME at or below the national median for each of the 10 surgical procedures evaluated for both initial prescription and 90-day total, whereas physicians in the West and South often prescribed more narcotics than the national median. The reason for the inverse relationship between regional prescribing habits and opioid deaths is beyond the scope of this investigation and is likely multifaceted. However, we speculated that increased awareness and physician sensitivity to the opioid epidemic may be one factor in the decreased amounts of prescribed narcotics in the areas most affected by deaths due to opioids.

In response to the increased awareness of the growing opioid epidemic, numerous studies have been published within all surgical subspecialties, including orthopaedics, comparing current practice guidelines, and proposing recommendations and strategies to reduce narcotic prescriptions.[1,3,5,6,8–14] One such study by Sabatino et al[8] highlighted the variability in prescriptions sizes between five procedure types including TKA, THA, RCR, carpal tunnel release, and lumbar decompression within a single institution's practice. Another study by Wyles et al[14] examined prescribing habits pre- and post-guideline implementation for patients undergoing total joint arthroplasty. Although a notable reduction in narcotic prescriptions was noted, there was no increased need for refills within the 30-day postoperative period. However, it should be noted that their recommended maximum OME for procedures such as TKA, THA, TSA, ankle fracture ORIF, distal radius fracture ORIF, shoulder and knee arthroscopies, ACL reconstruction, and even carpal tunnel release are well below nationwide orthopaedic prescribing practices for all procedures noted in our data. For example, the recommended maximum OME for patients undergoing TKA was 400, although it is unclear as to whether this is the recommended initial prescription size or the recommended 90-day total. Regardless, the data in our study demonstrates that both the initial prescription size (OME 495) and 90-day total (OME 1200) far exceed these recommendations.

Similarly, Kim et al[1] developed recommendations for maximum prescriptions for patients undergoing upper extremity surgical procedures based on a prospective observation of 1,416 patients. The authors proposed ≤10 pills for hand/wrist soft-tissue procedures, ≤20 pills for and/wrist fracture or joint procedures, and ≤30 pills for upper arm or shoulder procedures. This converts to 66 OME, 133 OME, and 200 OME, respectively, assuming the pills are 5-mg oxycodone equivalent. These recommended maximums are also well below the national median prescribing practices for carpal tunnel release (200 OME), distal radius fracture ORIF (380 OME), and TSA (750 OME). Furthermore, a notable number of patients required refills after these procedures, including up to 42.2% of patients undergoing TSA, raising the questions of (1) are the recommended maximums sufficient and (2) what is an acceptable threshold of the number of patients who will still require refills?

Variability between the initial and 90-day total OME prescribed was also observed between procedure types, reflecting the disparate number of refills required. Although the 90-day total OME for total joint arthroplasty was often two to three times the initial prescription, less disparate medians were observed for other procedures such as carpal tunnel release, arthroscopic meniscectomy, and distal radius fracture ORIF, which was confirmed by the relatively low number of refills after these procedures. Although this suggests that the initial prescription size was likely adequate, if not more so, for most patients undergoing such procedures, no doubt exists that the initial prescription size affects postoperative opioid consumption.[15] In a review of 33 health systems across Michigan, Howard et al demonstrated that the strongest effect on postoperative opioid consumption was the initial quantity of opioids prescribed. Specifically, for each OME prescribed, patients used an additional 0.53 OMEs, translating to an additional 5 pills consumed for every 10 pills prescribed.

Postoperative opioid consumption is evidently multifactorial, making the development and implementation of definitive recommendations challenging. Although previous studies have demonstrated that many more opioid pills are prescribed than are consumed, a notable number of patients were observed who still require refills after common orthopaedic procedures. This number increases depending on the type of procedure involved, whether that is soft-tissue–only procedures, fracture care, or total joint arthroplasty. A comprehensive and multimodal approach will be required to decrease postoperative opioid prescribing and consumption, including non-narcotic pharmaceuticals such as acetaminophen and nonsteroidal anti-inflammatories, local and regional blocks, and nonpharmaceutical alternatives, such as elevation and cryotherapy, biofeedback, and preoperative counseling to address the psychological aspect of the nociceptive stimulus. Physician and prescriber education about the scale and lack of uniformity of postoperative opioid prescriptions across the nation will help to realign pain management protocols and perhaps inform more appropriate normative prescribing habits. Establishing current normative prescribing practice habits for opioid-naive patients undergoing common orthopaedic procedures is one step toward creating a baseline that all prescribers can then compare and modify their individual practice patterns. Furthermore, creating and sharing standardized preoperative opioid use patient education materials and benchmark prescription recommendations could play an important role in creating positive and effective opioid stewardship between patients and prescribers.

Several inherent limitations of this study were observed that merit discussion. The MarketScan database collects information on adults and their dependents with private insurance coverage. Therefore, these results may not be generalizable to certain patient populations such as the underinsured, uninsured, or elderly cohort. Because MarketScan does not capture data on patients with Medicare, it is likely that this study was underpowered to find a difference in regional prescribing practices for patients undergoing total joint arthroplasty. In addition, the authors are unable to report on the amount of opioids actually consumed, but it can be assumed that patients who required refills consumed most of their initial prescription. Furthermore, it is possible that some patients required increased opioid prescriptions for a concomitant diagnosis that was not accounted for in this study. However, this confounder was mitigated by excluding patients who were taking narcotics preoperatively and excluding any patient that underwent an additional procedure in the postoperative period.

Despite these limitations, our study demonstrates that notable inter- and intra-regional variabilities exist in opioid prescribing patterns for many of the most common orthopaedic procedures. This study exposes regions of focus to reduce narcotic consumption after common orthopaedic procedures. Furthermore, these data demonstrated that median initial- and 90-day prescriptions varied notably depending on the type of surgery, and prescription amounts were lowest in the region most affected by the opioid epidemic. This information can be used to re-evaluate recommendations, serve as a benchmark for surgeons, and develop institutional and quality improvement guidelines to reduce excess postoperative opioid prescriptions.

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