Self-Reported Postoperative Opioid-Prescribing Practices Following Commonly Performed Orthopaedic Hand and Wrist Surgical Procedures

Abstract

Background: Although orthopaedic surgeons have been shown to prescribe excessive amounts of opioid analgesics postoperatively, the degree in which surgical trainees contribute to this trend is unknown. The purpose of this study was to compare self-reported opioid-prescribing behavior, factors influencing this behavior, and perceptions of patient opioid utilization and disposal between hand surgeons and trainees. Methods: Attending hand surgeons and trainees in hand, orthopaedic, and plastic surgery programs were invited to participate in a web-based survey including demographic characteristics; self-reported prescribing behavior specific to 4 procedures: open carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, and distal radial fracture open reduction and internal fixation; and perceptions and influencing factors. Analgesic medications were converted to morphine milligram equivalents and were compared across groups of interest using independent t tests or analysis of variance for each procedure. Results: A total of 1,300 respondents (266 attending surgeons, 98 fellows, 708 orthopaedic residents, and 228 plastic surgery residents) were included. Surgeons reported prescribing fewer total morphine milligram equivalents compared with residents for all 4 procedures. Personal experience was the most influential factor for prescribing behavior by surgeons and fellows. Although residents reported that attending surgeon preference was their greatest influence, most reported no direct opioid-related communication with attending surgeons. Conclusions: Residents self-report prescribing significantly higher morphine milligram equivalents for postoperative analgesia following commonly performed hand and wrist surgical procedures than attending surgeons. Poor communication between residents and attending surgeons may contribute to this finding. Residents may benefit from education on opioid prescription, and training programs should encourage direct communication between trainees and attending surgeons.

Postoperative Analgesia Protocol: A Resident‐Led Effort to Standardize Opioid Prescribing Patterns

“…Within academic medical centers, surgical residents and interns are frequently responsible for managing postoperative analgesia 3 . However, trainees tend to have the largest variability in prescribing practices among all members of the surgical team 3,25 . In a survey of 1,300 orthopedic and plastic surgeons performing four common hand surgeries, residents reported a greater tendency to prescribe higher‐potency opioids and in higher doses than attending surgeons and fellows.…”

“…A rapidly growing body of research has demonstrated multiple strategies for reducing postoperative opioid prescriptions, including reducing pill counts, inclusion of nonopioid alternatives, focused patient and provider education as well as preoperative medication regimes. 17‐24 However, within academic medical centers, the nearly 135,000 residents training across all specialties frequently serve as the primary prescribers of postoperative pain control regimens 3,15,25,26 . Resident physicians rarely receive formal training in opioid prescription management and most report low levels of comfort with prescribing these medications 3 .…”

“…Resident physicians rarely receive formal training in opioid prescription management and most report low levels of comfort with prescribing these medications 3 . Taken together, these factors likely contribute to the tendency of resident physicians to prescribe higher numbers and higher doses of opioids than fellows or staff physicians 3,4,25,27 …”

Cross-Cultural Comparison of Nonopioid and Multimodal Analgesic Prescribing in Orthopaedic Trauma

“…However, most opioid medications prescribed by surgeons are prescribed by trainees, 41 and although we recognize that residents are not permitted to prescribe opioids without direct attending oversight, previous studies have indicated that, in practice, resident prescribing occurs most commonly without direct communication with the attending. 42 Third, the lack of resources in Haiti poses challenges for the interpretation of our comparative study. 43 However, most responding Haitian residents (73%) believed that their indicated prescriptions were sufficient to manage postoperative pain.…”

Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery

“…Another hypothesis relates to differences in advertising, as opioid advertising is heavily curtailed in the Netherlands 24 , whereas aggressive pharmaceutical advertising in the U.S. has been posited as a potential contributor to the opioid epidemic 25 . Differences in analgesia training for residents may also contribute, although prior work indicates little training is provided to residents in either country [26][27][28] . Another potential contributing factor may be differences between Dutch and U.S. pain protocols, although this hypothesis remains subject to debate as no prior systematic comparison has been identified in the literature and Dutch protocols have been found to vary widely 29 .…”