Editor’s note: The following content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting, but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage at aaos.org/VirtualAAOS2020.
A study to determine the factors associated with increased postoperative opioid prescription use after a single admission for a single surgery in orthopaedic trauma patients identified a history of opioid use and longer length of surgery as significant. The study was presented by Austin J. Roebke, MD, a resident at the Ohio State University, as part of the Annual Meeting Virtual Experience.
The study found increased inpatient opioid use the day prior to discharge was the best predictor of increased opioid prescription in the six-week postoperative period. For each additional one pill of 5 mg oxycodone required in the day prior to discharge, patients required 2.6 additional 5 mg pills of oxycodone in the six-week postoperative period. Baseline opioid use, tobacco use, decreasing age, and longer length of surgery were found to be statistically significant factors for greater opioid use the day prior to discharge.
The study, which involved 200 patients categorized by anatomical location (hip, n = 50; pelvis, n = 50; periarticular, n = 50; long bone, n = 50), also found that pelvic fractures versus hip, periarticular, and long bone fractures required 20.25 additional pills of oxycodone in the total six-week postoperative period. Baseline opioid usage, tobacco use, and pelvic fractures were independent predictors of trips to the emergency department (ED) or another provider for pain control and use of opioids beyond six weeks.
“With the ongoing opioid epidemic, orthopaedic surgeons have a duty to prescribe opioids responsibly in the setting of the acute postoperative period,” Dr. Roebke told AAOS Now. “As orthopaedic surgeons, we often prescribe an individual’s first exposure to opioids and are one of the top prescribers of opioids across all specialties. Orthopaedic trauma patients have an increased risk of misuse and related complications compared to the general public. We sought to identify patient, injury, and surgery characteristics associated with increased or decreased postoperative opioid use in single-admission, single-surgery trauma patients.”
Dr. Roebke said a surprising finding was that 29 patients (14.5 percent) received opioids from an outside hospital or ED provider. “This ‘opioid shopping’ highlights the increased risk orthopaedic trauma patients have for opioid use and potential diversion,” he said.
“We believe our data can help surgeons prescribe a more personalized quantity of opioids to their patients at discharge because patient and surgical factors do play a role in opioid requirements,” Dr. Roebke said. “For example, a younger, unemployed individual with a pelvic fracture who uses a large number of opioids the day prior to discharge is likely at an increased risk of excessive postoperative opioid prescription. These patients would likely benefit from closer monitoring and a comprehensive pain plan utilizing a multimodal approach and appropriate expectations.”
In line with the current literature, patients with baseline opioid use consumed more opioids postoperatively and had more trips to the ED or a physician’s office for pain, Dr. Roebke noted. “This suggests special attention should also be paid to these patients. Again, these patients would likely benefit from a comprehensive pain plan utilizing a multimodal approach and appropriate education.”
With the knowledge of the patient, injury, and surgery risk factors that led to increased or decreased postoperative opioid use/consumption in single-admission, single-use trauma patients, more appropriate pre- and postoperative comprehensive, individualized pain plans may be put into place, Dr. Roebke said. “Further studies into the effectiveness of such pain plans may show a decrease in the unnecessary prescription of opioids. Furthermore, pain calculators, using risk factors described in our study, have been used in hand surgery to individually prescribe patients the appropriate number of opioids and reduce the overall number of opioids prescribed. We plan to create such a calculator for trauma patients.”
Limitations of the study are that it included only single-admission, single-surgery trauma patients from one state, one hospital system, and one surgeon. This may reduce the generalizability of the results. Second, for outpatient opioid prescription, actual consumption of opioids was not documented via pill counts. Among those patients who did not request at least one refill, the actual ingested quantity of opioids from the initial prescription is unknown. Third, because this study took place at a large academic medical center with rotating residents, “nonstandard prescribing practice of opioids was inevitable,” Dr. Roebke said. Fourth, there could have been other ED or clinic visits at hospitals that were not included due to lack of record of their occurrence in the medical center’s electronic medical record “Care Everywhere” tab. Fifth, patient self-reported subjective measures of pain or satisfaction with pain control were not collected as part of the analysis.
Dr. Roebke’s coauthors of “Patient and Surgical Factors Influence Postoperative Opioid Prescription in Single Admission, Single Surgery Orthopaedic Trauma Patients,” are John Mickley; Joshua Everhart, MD, MPH; Kanu Goyal, MD; and Thuan Ly, MD.
Terry Stanton is the senior medical writer for AAOS Now. He can be reached at firstname.lastname@example.org.