Opioid Prescriptions for Orthopaedic Patients Vary Greatly by Region of the US
However, patients undergoing total knee arthroplasty consistently receive more opioids than patients undergoing other orthopaedic surgeries, regardless of region of the country, according to a recent study.
Orthopaedic surgery patients in the West and South regions of the US were consistently given prescriptions for opioids at or greater than the national medians, according to a review article published in the Journal of the American Academy of Orthopaedic Surgeons that examines variability in opioid prescribing patterns for many common orthopaedic procedures.
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.  In addition, 1 in 16 patients becomes a chronic opioid user after a surgical procedure. [2,3]
“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, principal investigator and orthopaedic 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 orthopaedic community and their patients.”
The researchers conducted a retrospective analysis of claims data from 2015 to 2016 for privately insured subjects from the Truven Health MarketScan database. 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 orthopaedic procedures including:
- Total hip arthroplasty
- Total knee arthroplasty
- Total shoulder arthroplasty
- Anterior cruciate ligament reconstruction
- Arthroscopic meniscectomy
- Arthroscopic rotator cuff repair
- Bimalleolar ankle fracture open reduction and internal fixation
- Distal radius fracture open reduction and internal fixation
- Carpal tunnel release
- Single-level anterior cervical discectomy and fusion
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. For each region of the US, they analyzed the interquartile ranges (IQR) – the range between the 25th and 75th percentiles – for initial postoperative prescriptions and for 90-day total prescriptions.
“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,” said co-author Shane K. Woolf, MD, orthopaedic surgeon and chief of sports medicine at the Medical University of South Carolina. “What’s more concerning is these numbers only represent the middle 50% and don’t account for the outliers: the lower and upper 25%.”
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, 1 in 4 patients are being discharged with at least 2.67 times more opioids compared with other opioid-naive patients after undergoing the same procedure.
In addition, surgeons in the West and South consistently prescribed more opioids than the surgeons in the Midwest and Northeast for many procedures, including anterior cruciate ligament reconstruction, bimalleolar ankle fracture open reduction and internal fixation (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,” Dr. Slone said. “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.”
Inter-regional variabilities and IQRs increased when examining the 90-day total OME (initial prescription plus refills) prescribed for a given procedure. Overall, the team found that patients undergoing soft tissue-only procedures required the fewest refills, compared with 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 rotator cuff repair 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 US for this procedure was 1200, 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, 1 in 4 opioid-naive patients were given prescriptions for more than 3 times’ the amount of opioids than others undergoing the exact same procedure (IQR 700 to 2,350).
“These findings give us a starting point,” Dr. Slone said. “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.”
Traven SA, Brinton DL, Woolf SK, Leddy LR, Gottschalk MB, Slone HS. Notable variability in opioid-prescribing practices after common orthopaedic procedures. J Am Acad Orthop Surg. 2021 Mar 1;29(5):219-226. doi: 10.5435/JAAOS-D-19-00798.
- Kim N, Matzon JL, Abboudi J, et al: A prospective evaluation of opioid utilization after upper-extremity surgical procedures: Identifying consumption patterns and determining prescribing guidelines. J Bone Joint Surg Am 2016;98:e89.
- Overton HN, Hanna MN, Bruhn WE, Hutfless S, Bicket MC, Makary MA; Opioids After Surgery Workgroup: Opioid- prescribing guidelines for common surgical procedures: An expert panel consensus. J Am Coll Surgeons 2018;227:411-418.
- Brummett CM, Waljee JF, Goesling J, et al: New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg 2017;152:e170504.