Advertisement
Journal of Shoulder and Elbow Surgery

Opioid-prescribing patterns among shoulder and elbow surgeons: considerations for future prescription guidelines

Published:January 06, 2021DOI:https://doi.org/10.1016/j.jse.2020.12.001

      Background

      Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers.

      Methods

      In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents’ prescribing practices, and methods of patient counseling regarding opioid use and disposal.

      Results

      A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient’s symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines.

      Discussion

      To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.

      Level of evidence

      Keywords

      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Journal of Shoulder and Elbow Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • American Academy of Orthopaedic Surgeons
        Opioid use, misuse, and abuse in orthopaedic practice.
        (Available at:) (Accessed June 24, 2020)
        • American Academy of Orthopaedic Surgeons
        Symposium addresses pain management in the opioid epidemic.
        (Available at:) (Accessed June 24, 2020)
        • Bhashyam A.R.
        • Young J.
        • Qudsi R.A.
        • Parisien R.L.
        • Dyer G.S.M.
        Opioid prescribing patterns of orthopedic surgery residents after open reduction internal fixation of distal radius fractures.
        J Hand Surg Am. 2019; 44: 201-207.e2https://doi.org/10.1016/j.jhsa.2018.11.003
        • Bicket M.C.
        • Long J.J.
        • Pronovost P.J.
        • Alexander G.C.
        • Wu C.L.
        Prescription opioid analgesics commonly unused after surgery: a systematic review.
        JAMA Surg. 2017; 152: 1066-1071https://doi.org/10.1001/jamasurg.2017.0831
        • Centers for Disease Control and Prevention
        Opioid data analysis and resources. Drug overdose. CDC Injury Center.
        (Available at:) (Accessed June 24, 2020)
        • DeMik D.E.
        • Bedard N.A.
        • Dowdle S.B.
        • Burnett R.A.
        • McHugh M.A.
        • Callaghan J.J.
        Are we still prescribing opioids for osteoarthritis?.
        J Arthroplasty. 2017; 32: 3578-3582.e1https://doi.org/10.1016/j.arth.2017.07.030
        • Egan K.L.
        • Gregory E.
        • Sparks M.
        • Wolfson M.
        From dispensed to disposed: evaluating the effectiveness of disposal programs through a comparison with prescription drug monitoring program data.
        Am J Drug Alcohol Abuse. 2017; 43: 69-77https://doi.org/10.1080/00952990.2016.1240801
        • Elkassabany N.M.
        • Wang A.
        • Ochroch J.
        • Mattera M.
        • Liu J.
        • Kuntz A.
        Improved quality of recovery from ambulatory shoulder surgery after implementation of a multimodal perioperative pain management protocol.
        Pain Med. 2018; 20: 1012-1019https://doi.org/10.1093/pm/pny152
        • Food and Drug Administration
        Where and how to dispose of unused medicines.
        (Available at:) (Accessed June 26, 2020)
        • Gaspar M.P.
        • Pflug E.M.
        • Adams A.J.
        • Jacoby S.M.
        • Shin E.K.
        • Osterman A.L.
        • et al.
        Self-reported postoperative opioid-prescribing practices following commonly performed orthopaedic hand and wrist surgical procedures: a nationwide survey comparing attending surgeons and trainees.
        J Bone Joint Surg Am. 2018; 100: e127https://doi.org/10.2106/JBJS.17.01163
        • Golant A.
        • Christoforou D.
        • Zuckerman J.D.
        • Kwon Y.W.
        Return to sports after shoulder arthroplasty: a survey of surgeons’ preferences.
        J Shoulder Elbow Surg. 2012; 21: 554-560https://doi.org/10.1016/j.jse.2010.11.021
        • Golladay G.J.
        • Balch K.R.
        • Dalury D.F.
        • Satpathy J.
        • Jiranek W.A.
        Oral multimodal analgesia for total joint arthroplasty.
        J Arthroplasty. 2017; 32: S69-S73https://doi.org/10.1016/j.arth.2017.05.002
        • Halawi M.J.
        • Grant S.A.
        • Bolognesi M.P.
        Multimodal analgesia for total joint arthroplasty.
        Orthopedics. 2015; 38: e616-e625https://doi.org/10.3928/01477447-20150701-61
        • Hansen R.N.
        • Oster G.
        • Edelsberg J.
        • Woody G.E.
        • Sullivan S.D.
        Economic costs of nonmedical use of prescription opioids.
        Clin J Pain. 2011; 27: 194-202https://doi.org/10.1097/AJP.0b013e3181ff04ca
        • Kim N.
        • Matzon J.L.
        • Abboudi J.
        • Jones C.
        • Kirkpatrick W.
        • Leinberry C.F.
        • et al.
        A prospective evaluation of opioid utilization after upper-extremity surgical procedures: identifying consumption patterns and determining prescribing guidelines.
        J Bone Joint Surg Am. 2016; 98: e89https://doi.org/10.2106/JBJS.15.00614
        • Kumar K.
        • Gulotta L.V.
        • Dines J.S.
        • Allen A.A.
        • Cheng J.
        • Fields K.G.
        • et al.
        Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits.
        Am J Sports Med. 2017; 45: 636-641https://doi.org/10.1177/0363546517693665
        • Lipof J.S.
        • Thirukumaran C.P.
        • Greenstein A.S.
        • Zmich Z.
        • Lander A.
        • Ricciardi B.F.
        Postdischarge opiate-prescribing habits for primary THA and TKA: a survey of American Association of Hip and Knee Surgeons members.
        Orthopedics. 2019; 42: 361-367https://doi.org/10.3928/01477447-20190723-06
        • Lovecchio F.
        • Derman P.
        • Stepan J.
        • Iyer S.
        • Christ A.
        • Grimaldi P.
        • et al.
        Support for safer opioid prescribing practices a catalog of published use after orthopaedic surgery.
        J Bone Joint Surg Am. 2017; 99: 1945-1955https://doi.org/10.2106/JBJS.17.00124
        • Morris B.J.
        • Mir H.R.
        The opioid epidemic.
        J Am Acad Orthop Surg. 2015; 23: 267-271https://doi.org/10.5435/JAAOS-D-14-00163
        • Moutzouros V.
        • Jildeh T.R.
        • Khalil L.S.
        • Schwartz K.
        • Hasan L.
        • Matar R.N.
        • et al.
        A multimodal protocol to diminish pain following common orthopedic sports procedures: can we eliminate postoperative opioids?.
        Arthroscopy. 2020; 36: 2249-2257https://doi.org/10.1016/j.arthro.2020.04.018
        • National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse
        Bonnie R.J. Ford M.A. Pain management and the opioid epidemic. National Academies Press, Washington, DC2017
        • Overton H.N.
        • Hanna M.N.
        • Bruhn W.E.
        • Hutfless S.
        • Bicket M.C.
        • Makary M.A.
        • et al.
        Opioid-prescribing guidelines for common surgical procedures: an expert panel consensus.
        J Am Coll Surg. 2018; 227: 411-418https://doi.org/10.1016/j.jamcollsurg.2018.07.659
        • Raneses E.
        • Secrist E.S.
        • Freedman K.B.
        • Sohn D.H.
        • Fleeter T.B.
        • Aland C.M.
        Opioid prescribing practices of orthopaedic surgeons: results of a national survey.
        J Am Acad Orthop Surg. 2019; 27: e166-e172https://doi.org/10.5435/JAAOS-D-16-00750
        • Ruder J.
        • Wally M.K.
        • Oliverio M.
        • Seymour R.B.
        • Hsu J.R.
        Patterns of opioid prescribing for an orthopaedic trauma population.
        J Orthop Trauma. 2017; 31: e179-e185https://doi.org/10.1097/BOT.0000000000000834
        • Sabatino M.J.
        • Kunkel S.T.
        • Ramkumar D.B.
        • Keeney B.J.
        • Jevsevar D.S.
        Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures.
        J Bone Joint Surg Am. 2018; 100: 180-188https://doi.org/10.2106/JBJS.17.00672
        • Sheth U.
        • Mehta M.
        • Huyke F.
        • Terry M.A.
        • Tjong V.K.
        Opioid use after common sports medicine procedures: a systematic review.
        Sports Health. 2020; 12: 225-233https://doi.org/10.1177/1941738120913293
        • Shrank W.H.
        Our bulging medicine cabinets—the other side of medication nonadherence.
        N Engl J Med. 2011; 364: 1591-1593https://doi.org/10.1056/NEJMp1011624
        • Stanek J.J.
        • Renslow M.A.
        • Kalliainen L.K.
        The effect of an educational program on opioid prescription patterns in hand surgery: a quality improvement program.
        J Hand Surg Am. 2015; 40: 341-346https://doi.org/10.1016/j.jhsa.2014.10.054
        • Syed U.A.M.
        • Aleem A.W.
        • Wowkanech C.
        • Weekes D.
        • Freedman M.
        • Tjoumakaris F.
        • et al.
        Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.
        J Shoulder Elbow Surg. 2018; 27: 962-967https://doi.org/10.1016/j.jse.2018.02.039
        • Warner L.L.
        • Warner P.A.
        • Eldrige J.S.
        Orthopedic resident education on postoperative pain control: bridging knowledge gaps to enhance patient safety.
        Int J Med Educ. 2018; 9: 72-73https://doi.org/10.5116/ijme.5a91.2f7f
        • Warrender W.J.
        • Syed U.A.M.
        • Hammoud S.
        • Emper W.
        • Ciccotti M.G.
        • Abboud J.A.
        • et al.
        Pain management after outpatient shoulder arthroscopy: a systematic review of randomized controlled trials.
        Am J Sports Med. 2017; 45: 1676-1686https://doi.org/10.1177/0363546516667906
        • Welton K.L.
        • Kraeutler M.J.
        • McCarty E.C.
        • Vidal A.F.
        • Bravman J.T.
        Current pain prescribing habits for common shoulder operations: a survey of the American Shoulder and Elbow Surgeons membership.
        J Shoulder Elbow Surg. 2018; 27: S76-S81https://doi.org/10.1016/j.jse.2017.10.005