Safety issues with prescription medication—including the epidemic of opioid misuse and abuse, overprescribed antibiotics, and medication errors—have garnered significant media attention lately. One charge of the AAOS Patient Safety Committee is to educate members regarding prescription medication safety by monitoring alerts from the Food and Drug Administration, manufacturers, Centers for Disease Control and Prevention (CDC) Mortality and Morbidity Weekly Report (MMWR), press releases, and other publications. The goal is to ensure that AAOS members have the tools necessary to provide the safest possible care and that patients can be informed, active participants in their care.

Opioids
A recent issue of MMWR included information on a study conducted by researchers at the Johns Hopkins Bloomberg School of Public Health. They analyzed federal government data collected between 2000 and 2010 and found that the percentage of pain-related visits resulting in an opioid prescription nearly doubled—from 11 percent to 19 percent. The data were stratified by new-onset musculoskeletal pain and the results showed similar increases in opioid prescriptions. During the same period, the percentage of visits resulting in nonopioid prescriptions decreased significantly, from 38 percent of visits in 2000 to 29 percent of visits in 2010.

An increase in prescription opioids can lead to greater opportunities for misuse and abuse. The AAOS believes that the appropriate use of opioids is a legitimate concern, which is why the Patient Safety Committee is actively monitoring developments concerning opioids. The committee has published articles, developed tools for members and patients, and produced a webinar for continuing medical education credit regarding the optimal, effective, and safe means to control acute pain, as well as the potential harm of using opioid analgesics in patients with chronic pain.

Antibiotics
Increasing antibiotic use is also a concern. A recent study in the Journal of Antimicrobial Chemotherapy analyzed data from more than 238,000 ambulatory visits made by patients 18 and older to doctors’ offices, outpatient clinics, and emergency rooms in the United States between 2007 and 2009. Researchers found that doctors prescribed broad-spectrum antibiotics more than 60 percent of the time; in addition, 25 percent of these prescriptions were unnecessary because the infection was caused by a virus.

Unnecessary prescription of antibiotics can increase the risk that bacteria will develop resistance, place patients at greater risk of an infection from a resistant organism, and introduce potential iatrogenic harm (such as diarrhea or an allergic reaction). It also misuses resources and reinforces maladaptive illness behaviors. Orthopaedic surgeons need to take care with use of antibiotics to ensure that the ability to develop new antibiotics keeps pace with the development and dissemination of resistance.

To help members understand the appropriate use of antibiotics, the AAOS has created several resources including an information statement on “Recommendations for the Use of Intravenous Antibiotic Prophylaxis in Primary Total Joint Arthroplasty.” This statement parallels the guidelines established by the Surgical Care Improvement Project and includes recommendations on the appropriate selection, timing, and duration of antibiotic therapies. Online modules educating members on the prudent selection and use of antibiotics have also been developed.

In 2010, the AAOS supported the Infectious Disease Society of America’s “10 x ’20 Initiative,” a collaborative effort seeking to develop 10 new antibiotics by 2020. The AAOS also supports the Limited Population Antibacterial Drug approval mechanism, which would create a new regulatory pathway for bringing to market drugs intended to treat the most serious bacterial infections where insufficient therapeutic options exist.

Medication errors
CDC data indicate that 82 percent of American adults take at least one prescription medication and 29 percent take five or more. Annually, 700,000 emergency department visits and 120,000 hospitalizations are due to adverse drug events (ADEs), accounting for up to $3.5 billion in additional medical costs. The CDC projects that the number of ADEs will likely grow due to factors such as the development of new medications and an aging American population.

The AAOS recommends the following tools, which have been shown to significantly reduce medication errors:

• computerized physician order entry
• computerized decision support systems
• computerized monitoring of adverse drug events
• pharmacist-assisted rounds
• high-risk drug protocols
• verbal order verification

Conclusion
The AAOS Patient Safety Committee will continue to keep medication safety a priority, educating members on advances in antibiotic research and development and new regulations surrounding existing medications.

Additional medication safety topics for consideration by the AAOS Patient Safety Committee can be emailed to Paul Zemaitis at zemaitis@aaos.org

Dana McClure-Thomas is the research coordinator and Paul Zemaitis is the regulatory/patient safety analyst in the AAOS department of research & scientific affairs. David C. Ring, MD is a member of the AAOS Patient Safety Committee.

Additional Resources:

Opioids

• U.S. Food and Drug Administration: A Guide to Safe Use of Pain Medication.
• Federation of State Medical Boards: Responsible Opioid Prescribing: A Physician's Guide
• American Academy of Orthopaedic Surgeons: Safe Medication Practices
• Gebhardt M: Communication Matters. AAOS Now May 2011;5:40–41

Antibiotics
American Academy of Family Physicians: Antibiotics: When They Can and Can’t Help.

References:

1. Daubresse M, Chang H, Yu Y, et al: Ambulatory Diagnosis and Treatment of Nonmalignant Pain in the United States, 2000-2010. Med Care 2013 Oct;51(10):870–878.
2. Fleeter TB, Ashburn M, Hertz S, Ring DC, Sohn DH: AAOS Webinar: Risk Evaluation and Management Strategies for Prescribing Opioids. http://www5.aaos.org/oko/cme/templates/template_2/information.cfm?topic=CME261
3. American Academyof Orthopaedic Surgeons: Managing Pain With Medications After Orthopaedic Surgery. http://orthoinfo.aaos.org/topic.cfm?topic=A00650
4. Shapiro DJ, Hicks LA, Pavia AT, Hersh AL: Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09. J Antimicrob Chemother (2013) doi: 10.1093/jac/dkt301 First published online: July 25, 2013
5. Information Statement: Recommendations for the Use of Intravenous Antibiotic Prophylaxis in Primary Total Joint Arthroplasty. American Academy of Orthopaedic Surgeons, Rosemont, Ill. http://www.aaos.org/about/papers/advistmt/1027.asp
6. The Joint Commission Surgical Care Improvement Project http://www.jointcommission.org/surgical_care_improvement_project/
7. Prokuski L: Prophylactic Antibiotics in Orthopaedic Surgery. J Am Acad Orthop Surg May 2008;16; 5;283–293. http://orthoportal.aaos.org/jaaos/abstract.aspx?article=JAAOS_16_5_283
8. Callaghan J: Comment letter on Infectious Disease Society of America’s 10 x ’20 Initiative. http://www.aaos.org/research/committee/ptsafety/Letter_IDSA10x20.pdf
9. Centers for Disease Control and Prevention: Medication Safety Basics. http://www.cdc.gov/medicationsafety/basics.html
10. Information Statement: Prevention of Medication Errors. American Academy of Orthopaedic Surgeons, Rosemont, Ill. http://www.aaos.org/about/papers/advistmt/1026.asp