Published 5/9/2019
ROSEMONT, Illinois (May 9, 2019) — A new research article published in the May 1 issue of the Journal of the American Academy of Orthopaedic Surgeons found that prolonged opioid use following surgery for traumatic musculoskeletal injuries was related to the quantity of the initial opioid prescribed upon discharge. Despite the common belief that prolonged use is associated with the type of opioid selected by the physician, these findings demonstrate that orthopaedic surgeons and patients need to monitor the amount of opioids being prescribed and not assume that one type of opioid is “safer” than another.
“One of the frequent myths we encounter among clinicians is that some types of opioids, such as hydromorphone, are more dangerous than others,” said senior study author and orthopaedic surgeon Marilyn Heng, MD, MPH, FRCSC. “The goal of our study was to assess if the initial opiate type prescribed to postoperative, opiate-naïve orthopaedic trauma patients was associated with prolonged opioid use. Our findings demonstrate how current beliefs about the mechanism of prolonged use may be confounded.”
The retrospective study conducted by Matthew Basilico, AB, AM, Mitchel Harris, MD and Abhiram R. Bhashyam, MD, MPP with Dr. Heng consisted of 17,961 adult opiate-naïve patients who had a traumatic musculoskeletal injury and underwent surgery within 14 days of presentation. In order to qualify for the sample, patients had no prior history of opioid abuse and hadn’t taken opioids in the six months prior to their injury.
Since different opioids have different strengths per milligram, the researchers calculated the morphine milligram equivalents (MME) — a standardized dosing unit that allows for comparison across opioid types — among all opioids prescribed to the sample population upon discharge from surgery.
Not only did the study find that prolonged opiate use (defined as usage beyond 90 days of the initial prescription) correlates to the overall MME prescribed at discharge, rather than opioid type, but the researchers identified a pattern of failure to properly calculate an equivalence dose among opioid types. According to the study, this lack of conversion can result in higher doses and place patients at an increased risk for prolonged use.
“There tends to be bias in how providers prescribe drugs, and it’s focused on the number of tablets, instead of MME. However, it’s really the amount of MMEs that make a difference,” said Dr. Heng.
For example, if an equivalence calculation isn’t performed when converting 20 pills of oxycodone to hydromorphone, a patient who is prescribed 20 pills of hydromorphone would receive a dose increase of more than 142% in terms of initial opioid quantity.
“This often leads to the notion that certain opioid types appear to be associated with higher odds of complications, when in fact, we are prescribing much more of the stronger drug, which can lead to dependency,” said Dr. Heng.
According to the National Survey on Drug Use and Health, prescription opioids significantly contributed to the rise in drug-related deaths over the past decade. With orthopaedic surgeons ranking as the third highest prescriber of opioids among U.S. physicians, these findings provide the next step toward understanding the relationship between opioid prescribing and potential long-term patient dependency.
“One of the frequent myths we encounter among clinicians is that some types of opioids, such as hydromorphone, are more dangerous than others,” said senior study author and orthopaedic surgeon Marilyn Heng, MD, MPH, FRCSC. “The goal of our study was to assess if the initial opiate type prescribed to postoperative, opiate-naïve orthopaedic trauma patients was associated with prolonged opioid use. Our findings demonstrate how current beliefs about the mechanism of prolonged use may be confounded.”
The retrospective study conducted by Matthew Basilico, AB, AM, Mitchel Harris, MD and Abhiram R. Bhashyam, MD, MPP with Dr. Heng consisted of 17,961 adult opiate-naïve patients who had a traumatic musculoskeletal injury and underwent surgery within 14 days of presentation. In order to qualify for the sample, patients had no prior history of opioid abuse and hadn’t taken opioids in the six months prior to their injury.
Since different opioids have different strengths per milligram, the researchers calculated the morphine milligram equivalents (MME) — a standardized dosing unit that allows for comparison across opioid types — among all opioids prescribed to the sample population upon discharge from surgery.
Not only did the study find that prolonged opiate use (defined as usage beyond 90 days of the initial prescription) correlates to the overall MME prescribed at discharge, rather than opioid type, but the researchers identified a pattern of failure to properly calculate an equivalence dose among opioid types. According to the study, this lack of conversion can result in higher doses and place patients at an increased risk for prolonged use.
“There tends to be bias in how providers prescribe drugs, and it’s focused on the number of tablets, instead of MME. However, it’s really the amount of MMEs that make a difference,” said Dr. Heng.
For example, if an equivalence calculation isn’t performed when converting 20 pills of oxycodone to hydromorphone, a patient who is prescribed 20 pills of hydromorphone would receive a dose increase of more than 142% in terms of initial opioid quantity.
“This often leads to the notion that certain opioid types appear to be associated with higher odds of complications, when in fact, we are prescribing much more of the stronger drug, which can lead to dependency,” said Dr. Heng.
According to the National Survey on Drug Use and Health, prescription opioids significantly contributed to the rise in drug-related deaths over the past decade. With orthopaedic surgeons ranking as the third highest prescriber of opioids among U.S. physicians, these findings provide the next step toward understanding the relationship between opioid prescribing and potential long-term patient dependency.
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Disclosure
From the Department of Economics (Mr. Basilico), Harvard University and Harvard Medical School, the Harvard Combined Orthopaedics Residency Program (Dr. Bhashyam), the Department of Orthopaedic Surgery (Dr. Harris), Massachusetts General Hospital, Harvard Orthopaedic Trauma Initiative, Harvard Medical School, and the Department of Orthopaedics (Dr. Heng), Massachusetts General Hospital, Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Cambridge, MA. Correspondence to Dr. Bhashyam: abhashyam@partners.org Dr. Heng or an immediate family member serves as a board member, owner, officer, or committee member of the New England Orthopaedic Society. None of the following authors or any immediate family member hasreceived anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Mr. Basilico, Dr. Bhashyam, and Dr. Harris. Mr. Basilico and Dr. Bhashyam contributed equally to this work. J Am Acad Orthop Surg 2019;27: e423-e429 DOI: 10.5435/JAAOS-D-17-00663 Copyright 2018 by the American Academy of Orthopaedic Surgeons.
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