An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery

Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan

Importance

There is growing evidence that opioids are overprescribed following surgery. Improving prescribing requires understanding factors associated with opioid consumption.

Objective

To describe opioid prescribing and consumption for a variety of surgical procedures and determine factors associated with opioid consumption after surgery.

Design, Setting, and Participants

A retrospective, population-based analysis of the quantity of opioids prescribed and patient-reported opioid consumption across 33 health systems in Michigan, using a sample of adults 18 years and older undergoing surgery. Patients were included if they were prescribed an opioid after surgery. Surgical procedures took place between January 1, 2017, and September 30, 2017, and were included if they were performed in at least 25 patients.

Exposures

Opioid prescription size in the initial postoperative prescription.

Main Outcomes and Measures

Patient-reported opioid consumption in oral morphine equivalents. Linear regression analysis was used to calculate risk-adjusted opioid consumption with robust standard errors.

Results

In this study, 2392 patients (mean age, 55 years; 1353 women [57%]) underwent 1 of 12 surgical procedures. Overall, the quantity of opioid prescribed was significantly higher than patient-reported opioid consumption (median, 30 pills; IQR, 27-45 pills of hydrocodone/acetaminophen, 5/325 mg, vs 9 pills; IQR, 1-25 pills; P < .001). The quantity of opioid prescribed had the strongest association with patient-reported opioid consumption, with patients using 0.53 more pills (95% CI, 0.40-0.65; P < .001) for every additional pill prescribed. Patient-reported pain in the week after surgery was also significantly associated with consumption but not as strongly as prescription size. Compared with patients reporting no pain, patients used a mean (SD) 9 (1) more pills if they reported moderate pain and 16 (2) more pills if they reported severe pain (P < .001). Other significant risk factors included history of tobacco use, American Society of Anesthesiologists class, age, procedure type, and inpatient surgery status. After adjusting for these risk factors, patients in the lowest quintile of opioid prescribing had significantly lower mean (SD) opioid consumption compared with those in the highest quintile (5 [2] pills vs 37 [3] pills; P < .001).

Conclusions and Relevance

The quantity of opioid prescribed is associated with higher patient-reported opioid consumption. Using patient-reported opioid consumption to develop better prescribing practices is an important step in combating the opioid epidemic.

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

BACKGROUND

Our institution developed a 1-hour mandatory narcotics-prescribing education program as well as postoperative opioid-prescribing guidelines in response to the opioid epidemic. The purpose of this study was to evaluate the effect of this hospital-wide opioid education and subsequent institution of postoperative opioid guidelines on opioid-prescribing practices after ambulatory surgery.

METHODS

This retrospective study was performed at 1 academic orthopaedic hospital. In November 2016, a 1-hour mandatory opioid education program was completed by all hospital prescribers. Postoperative opioid guidelines were then developed and were disseminated in February 2017. All postoperative narcotic prescriptions after ambulatory procedures performed by 3 separate services (hand, sports, and foot and ankle services) were evaluated over 4 months prior to and after the mandatory opioid education and subsequent release of service-specific guidelines.

RESULTS

Overall, there was a significant decrease in pills and total oral morphine equivalents prescribed after dissemination of guidelines compared with the pre-intervention cohort procedures (p < 0.001) performed by the sports and hand services. With regard to the sports medicine service, the mean difference in pills prescribed was 6.47 pills (95% confidence interval [CI], 5.4 to 7.5 pills) for knee arthroscopy, 5.6 pills (95% CI, 2.5 to 8.7 pills) for shoulder arthroscopy, and 16.3 pills (95% CI, 13.6 to 19.1 pills) for hip arthroscopy. With regard to the hand service, the mean difference in pills prescribed was 13.0 pills (95% CI, 10.2 to 15.8 pills) for level-1 procedures, 12.4 pills (95% CI, 9.9 to 15.0 pills) for carpal tunnel release, and 21.7 pills (95% CI, 18.0 to 25.3 pills) for distal radial fractures. The decrease in pills prescribed in the post-intervention cohort amounts to almost 30,000 fewer opioid pills prescribed per year after these 6 procedures alone. There was no significant change (p > 0.05) in either the number of pills or the oral morphine equivalents prescribed after any of the 3 procedures performed by the foot and ankle service (ankle arthroscopy, bunion surgery, and Achilles tendon repair).

CONCLUSIONS

We developed a prescriber education program and followed up with consensus-based guidelines for postoperative opioid prescriptions. These interventions caused a significant decrease in excessive opioid-prescribing practices after ambulatory orthopaedic surgery at our hospital. We urge initiatives by national orthopaedic organizations to develop and promote education programs and procedure and disease-specific opioid-prescribing guidelines.

Perioperative Opioid Analgesics and Hip Arthroscopy: Trends, Risk Factors for Prolonged Use, and Complications

PURPOSE

The purpose of this article is to (1) examine trends in preoperative and prolonged postoperative opioid analgesic use in patient undergoing hip arthroscopy, (2) characterize risk factors for prolonged opioid analgesic use following hip arthroscopy, and (3) explore preoperative and prolonged postoperative opioid analgesic use as independent risk factors for complications following hip arthroscopy.

METHODS

A private insurance database was queried for patients undergoing hip arthroscopy from 2007 to 2015 with a minimum of 6 months of follow-up. Independent risk factors for prolonged opioid analgesic use were determined. Preoperative and prolonged opioid analgesic use as risk factors for complications were examined.

RESULTS

There was a significantly decreasing trend in preoperative (P = .002) and prolonged postoperative (P = .009) opioid analgesic use. The most significant risk factor for prolonged postoperative opioid analgesic use was preoperative use (odds ratio [OR], 3.61; P < .0001). Other preoperative prescriptions, including muscle relaxants (OR, 1.5; P < .0001) and anxiolytics (OR, 2.0; P < .0001), were also significant risk factors. Preoperative opioid analgesic use was a significant risk factor for postoperative complications, including emergency room visits (OR, 2.1; P < .0001) and conversion to total hip arthroplasty (THA) (OR, 1.6; P < .0001). Prolonged postoperative opioid analgesic use was associated with a higher risk of revision hip arthroscopy (OR, 1.4; P = .0004) and conversion to THA (OR, 1.8; P < .0001).

CONCLUSIONS

More than a quarter of patients undergoing hip arthroscopy continue to receive opioid analgesic prescriptions more than 3 months postoperatively. The most significant risk factor for prolonged opioid analgesic use is preoperative opioid analgesic use. Additionally, anxiolytics, substance use or abuse, morbid obesity, and back pain were among the more notable risk factors for prolonged postoperative opioid analgesic use. Preoperative and prolonged postoperative opioid analgesic use was associated with a higher likelihood of several adverse effects/complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment Innovation in Orthopedic Surgery: A Case Study from Hospital for Special Surgery

Excessive prescribing of pain medications after surgery has contributed to the epidemic of opioid misuse and diversion in the United States. Pain specialists may be particularly well situated to address these issues. We describe an attempt to reverse the trend at an orthopedic surgical hospital by implementing a peri-operative assessment and treatment service which minimizes preoperative opioid use, when necessary implements addiction treatment, and encourages early tapering from opioids.