TAYLOR PASKEY, BS
ASIF ILYAS, MD, MBA, FACS
Orthopaedic Surgeons write 5.8% of all opioid prescriptions, behind: Family Practitioners (20.5%), Internists (15.7%), Nurse Practitioners (9.9%), Physician Assistants (9.3%), Pain Specialists (8.9%), and Dentists (8.6%).
Orthopaedic Surgeons rank 3rd in terms of number of opioid prescriptions written per provider with 438 prescriptions written per provider annually, behind: Pain Medicine specialists (1,315) and Physical Medicine & Rehabilitation physicians (1,023).
When deliberate pain management strategies have been employed including patient education, prescribing limits, and the use of multi-modal pain strategies, Orthopaedist Surgeons have been able to reduce their opioid prescribing rates.
In the 1990s, pain was labeled the “fifth vital sign.” In surgery, specifically, post-operative pain levels were directly correlated to patient satisfaction.1 Between pressures to treat post-operative pain aggressively, the poorly understood addictive profile of opioids, and FDA approval and marketing of OxyContin in 1995, opioid prescribing increased from 76 million annual prescriptions in 1990 to 219 million annual prescriptions by 2011.1 By 2012, surgery had the second highest opioid prescribing rate behind pain medicine.2 Moreover, the subspecialty of orthopaedics was recognized as having particularly high opioid prescribing rates compared to its surgical counterparts. In 2009, orthopaedic surgeons were ranked as the third highest prescribers of opioids among U.S. physicians, and were responsible for prescribing 7.7% of all opioids that year alone.3 With this information in mind, has the field of orthopaedics improved its current opioid prescribing patterns, and how do orthopaedic surgeons rank compared to other specialties?
Levy et al. analyzed opioids dispensed from 90% of U.S. pharmacies, reflecting 970,902 prescribers, from July 1, 2016 to June 30, 2017, using the IQVIA Prescriber Profile. The field of orthopaedics only represented 5.8% of the 209,498,112 opioid prescriptions during this 12-month period, with family medicine (20.5%), internal medicine (15.7%), nurse practitioners (9.9%), physician assistants (9.3%), pain medicine (8.9%), and dentists (8.6%) responsible for prescribing the highest percentages. Additionally, the most common specialty groups noted to prescribe opioids consisted of internal medicine (16.4%), dentists (15.8%), nurse practitioners (12.3%), and family medicine (10.3%). Among specialties with the highest opioid prescriptions per prescriber, orthopaedic surgery (438.7) ranked third behind both pain medicine (1,314.9) and physical medicine and rehabilitation (1,023.1).4
In response, the orthopaedic field has begun to tackle this public health crisis and improve postoperative opioid prescribing habits. Across the U.S., multimodal analgesia approaches have been employed to manage post-operative pain in orthopaedics, as evidence shows administering pain medications of different classes (i.e. nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, corticosteroids, etc.) concomitantly and via different routes, affords superior pain relief relative to opioids alone. 5 Pain management is especially important in orthopaedics because procedures often require deep musculoskeletal dissection that can generate higher levels of post-operative pain. Additionally, in response to concerns of physician over-prescribing,6 opioid-tapering regimens have been developed and employed nationally to help standardize prescribing practices. A Boston Medical Center study observed that after 9 months of enforcing uniform post-operative opioid tapering for orthopaedics, utilizing the 24- hour pre-discharge opioid usage, a 24% reduction in opioid prescribing occurred.7 Furthermore, to provide patient-centered care and assist with pre-operative planning, orthopaedic surgeons have worked to identify clinical elements of a patient’s history to determine those at increased risk for opioid dependence and intolerance. The field has also emphasized ensuring patient access to education regarding post-operative pain management and setting clear expectations with patients during surgical planning.1
In summary, orthopaedic surgeons have historically been high opioid prescribers based on the number of prescriptions per provider on average. However, recently published studies and innovative interventions demonstrate that the field is improving its own opioid prescribing patterns through educational remodeling and clinical innovation.
1. Labrum, J. T., & Ilyas, A. M. (2017). The Opioid Epidemic. JBJS Reviews, 5(8). https://doi.org/10.2106/jbjs.rvw.16.00124
2. Guy GP, Zhang K. Opioid prescribing by specialty and volume in the U.S. Am J Prev Med. 2018;55(5):e153-e155. doi:10.1016/j.amepre.2015.02.020
3. Morris, B. J., & Mir, H. R. (2015). The Opioid Epidemic. Journal of the American Academy of Orthopaedic Surgeons, 23(5), 267–271. https://doi.org/10.5435/jaaos-d-14-00163
4. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. Am J Prev Med. 2015;49(3):409-413.
5. Trasolini NA, McKnight BM, Dorr LD. The Opioid Crisis and the Orthopedic Surgeon. J Arthroplasty. 2018;33(11):3379-3382.e1. doi:10.1016/j.arth.2018.07.002
6. Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012;37(4):645-650. doi:10.1016/j.jhsa.2012.01.035
7. Chen EY, Betancourt L, Li L, Trucks E, Marcantonio A, Tornetta P 3rd. Standardized, Patientspecific, Postoperative Opioid Prescribing After Inpatient Orthopaedic Surgery. J Am Acad Orthop Surg. 2020;28(7):e304-e318. doi:10.5435/JAAOS-D-19-00030