PANKTI ACHARYA, MPH
ASIF ILYAS, MD, MBA, FACS
Formal Opioid-prescribing education of orthopaedic surgical residents resulted in a statistically significant increase in opioid knowledge.
Formal Opioid-prescribing education of orthopaedic surgical residents resulted in a statistically significant decrease in prescribed opioid and increased use of opioid-sparing pain management modalities.
Educating residents on evidenced-based opioid-prescribing and pain management strategies that could result in less dissemination of prescription opioids and minimizing the risks of diversion.
Management of postoperative pain in orthopedic surgery is an area of concern given the current opioid crisis. Orthopaedic surgeons are the third highest prescribers of opioids amongst all medical specialists.1 Traditionally, patients were managed predominately with opioid medications; however, with increasing rates of addiction, orthopedic surgeons have begun to emphasize a multimodal approach to pain management with the goal of limiting the number of opioids prescribed and consumed.2 With these adaptations, orthopedists aim to diminish rates of dependence and addiction while maintaining adequate patient satisfaction.3-4
Excessive and prolonged opioid use post-operatively can have a number of deleterious outcomes, including poor surgical results, opioid tolerance, opioid abuse, and even overdose related death.3 The CDC has urged providers to take caution when prescribing opioids as these drugs pose risks to all patients. According to the National Survey on Drug Use and Health, individuals between 12 and 49 years of age that have used prescription pain relief are 19 times more likely to use heroin, and 40-80% of heroin users report prescription opioid abuse that preceded heroin commencement.5 Opioids also pose risks to the larger community through pill dispersion. This highlights the importance of prescribing the correct number of pills for patient pain control, but limiting excess that may be diverted.
Resident physicians are often responsible for prescribing opioids. A recent study found that 19% of orthopedic residents prescribed more than 7 days of opioids for hypothetical patients following a distal radius open reduction internal fixation, despite state laws prohibiting first time opioid prescriptions for more than 7 days.6 While most residents are mandated to partake in some form of opioid prescription training, usually governed by their respective state medical licensing board, there is little additional formal training pertaining to this area. Therefore, providing orthopedic surgery resident physicians with opioid education is an area for potential improvement.
The study consisted of a questionnaire on opioid perceptions, knowledge, and prescribing behaviors which was completed by orthopaedic surgery residents before and after an educational intervention. A total of 60 orthopaedic surgery residents were recruited from 3 urban academic medical centers in Philadelphia, Pennsylvania, a city and state strongly affected by the opioid crisis. Participation was voluntary, and ultimately 49 orthopaedic surgery residents participated. IRB approval was obtained per institutional protocols prior to study initiation. The study intervention consisted of a 30-question pre-test, followed by a 7-minute pre-recorded lecture reviewing information on opioid pharmacology, opioid-related complications, current opioid crisis statistics, and evidence-based opioid-prescribing strategies for common orthopaedic procedures. After the pre-recorded lecture, a post-test with the same 30-questions was administered on a different day.
A statistically significant increase in resident confidence concerning their opioid prescribing (p<0.05) and their knowledge of alternative pain management therapies (p<0.05). This was accompanied by an objective improvement in knowledge of state prescribing laws and of metrics regarding the opioid epidemic. Hypothetical opioid pills prescribed after common orthopedic procedures also decreased between the pre and post-tests.
Figure: Resident confidence levels on opioid prescribing
Morris BJ, Mir HR. The opioid epidemic: impact on orthopaedic surgery. J. Am. Acad. Orthop. Surg. 2015;23(5):267-271. doi:10.5435/JAAOS-D-14-00163.
Miller A, Matzon J, Kim, N, Ilyas AM. Postoperative Pain Management Following Carpal Tunnel Release: A Prospective Cohort Evaluation. HAND.
Labrum J, Ilyas AM. The Opioid Epidemic: Post-Operative Pain Management Strategies in Orthopaedics. JBJS Reviews 2017 Aug;5(8):e14.
Miller A, Ilyas AM. Prospective Evaluation of Opioid Consumption Following Hand Surgery Performed Wide Awake Versus With Sedation. HAND.
CDC Guideline for Prescribing Opioids for Chronic Pain | Drug Overdose | CDC Injury Center. Available at: https://www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed March 20, 2019.
Bhashyam AR, Young J, Qudsi RA, Parisien RL, Dyer GSM. Opioid prescribing patterns of orthopedic surgery residents after open reduction internal fixation of distal radius fractures. J Hand Surg Am 2019;44(3):201-207.e2. doi:10.1016/j.jhsa.2018.11.003.