Study examines the variability in opioid prescriptions for common orthopedic procedures

A new review article published in the March issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) examines the variability that exists in opioid prescribing patterns across the United States for many common orthopedic procedures.

While the Northeast and Midwest were most impacted by the opioid epidemic, the study found that patients in the West and South consistently were given prescriptions at or greater than the national medians. These regional and national variations in opioid prescribing practices can serve as a benchmark for orthopedic surgeons to help develop guidelines to reduce excess postoperative opioid prescriptions.

The opioid epidemic continues to impact the United States as Americans consume 80% of the world's global opioid supply while representing only 5% of the world's cohort. Additionally, one in 16 patients becomes a chronic opioid user after a surgical procedure.

"Since surgeons are one of the highest prescribers of opioid medications, we wanted a greater understanding of prescribing habits, many of which are based on tradition and dogma, rather than driven by data," said Harris S. Slone, MD, FAAOS, principal investigator and orthopedic surgeon at Medical University of South Carolina in Charleston.

"By understanding the scale and variability of prescribing habits across the country, we're able to work towards more appropriate prescribing practices and recommendations that are better for the orthopedic community and their patients."

Dr. Slone, along with co-author Shane K. Woolf, MD, FAAOS, and their collaborators, conducted a retrospective analysis of claims data for privately insured subjects from the Truven Health MarketScan database between 2015 and 2016. They identified a total of 73,921 opioid-naive patients grouped by region (Northeast, South, Midwest and West) who underwent 10 of the most common orthopedic procedures including:

• Carpal tunnel release
• Anterior cruciate ligament (ACL) reconstruction
• Arthroscopic meniscectomy
• Bimalleolar ankle fracture open reduction and internal fixation (ORIF)
• Distal radius fracture ORIF
• Arthroscopic rotator cuff repair (RCR)
• Single-level anterior cervical discectomy and fusion (ACDF)
• Total shoulder, hip, and knee arthroplasties

The team converted opioid prescriptions related to the surgery to oral morphine equivalents (OME) providing a baseline equivalent for the various opioid types and strengths prescribed to these patients. They analyzed the interquartile ranges (IQR)––the range between the 25th percentile and 75th percentile––for the various regions for initial postoperative prescriptions and 90-day total prescriptions for patients undergoing the selected procedures.

While the median OME was relatively consistent between regions for patients undergoing these procedures, the IQR range for OMEs was tremendous and demonstrates that there are providers across the country who are prescribing way more than the median. What's more concerning is these numbers only represent the middle 50% and don't account for the outliers––the lower and upper 25%."

Dr. Shane K. Woolf, Orthopedic Surgeon and Chief, Sports Medicine, Medical University of South Carolina

The widest IQRs were seen in the initial prescriptions for patients undergoing total knee arthroplasty (TKA). Although the national median OME was 495, the IQR ranged from 320 in the 25th percentile to 750 in the 75th percentile-;a difference of 430 OME.

Similar variations were seen within regions of the country as well. For patients undergoing TKA in the South, the range in IQR was from 300 to 800, a difference of 500 OME. In other words, one in four patients are being discharged with at least 2.67 times more opioids compared with other opioid-naive patients after undergoing the same procedure.

Additionally, the West and South consistently prescribed more opioids than the Midwest and Northeast for many procedures including ACL reconstruction, bimalleolar ankle fracture ORIF, carpal tunnel release, distal radius fracture ORIF, TKA and total shoulder arthroplasty.

"We initially hypothesized that areas hit hard by the opioid epidemic, such as the Midwest and Northeast, would have more narcotic prescriptions," said Dr. Slone. "But in fact, we saw the opposite as these areas generally had lower rates of narcotics prescribed for the same procedure in the West and South. While this relationship was not part of our investigation, we can speculate that increased awareness and laws to prevent opioid abuse and related deaths have led prescribers to be more conscious and careful with their prescribing practices."

Interregional variabilities and IQRs increased when examining the 90-day total (includes initial prescription, plus refills) OME prescribed for a given procedure. Overall, the team found that patients undergoing soft-tissue-only procedures required the fewest refills, compared to patients undergoing total joint arthroplasty, who required the most due to the more involved nature of the surgery.

Additional details of the 90-day findings include:

Notable intraregional variability was also observed. For example, although the median prescription for patients undergoing arthroscopic RCR in the West was 625 OME, the IQR ranged from 425 to 1,200-;a difference of 775 OME.

The greatest number of opioids prescribed consistently across all regions was for patients undergoing TKA. The median 90-day OME across the United States for this procedure was 1,200, which was more than twice that of the median OME for the initial prescription (495 OME).

A wide range in IQR was noted for patients undergoing TKA, with the most intraregional variability in prescriptions seen in the West. For patients undergoing TKA in this region, one in four opioid-naive patients were given prescriptions for more than three times the amount of opioids than others undergoing the exact same procedure (IQR 700 to 2,350).

"These findings give us a starting point," said Dr. Slone. "From here we can have more deliberate conversations with our colleagues about prescribing guidelines and best practices to mitigate and manage pain pre- and post-operatively in order to be better stewards of our patient's health and reduce the number of opioids prescribed."