Haphazard Prescribing for Opioid-Naïve Patients After Knee Arthroscopy?
by Elizabeth Hofheinz, M.P.H., M.Ed.
As patients prescribed opioids typically have remaining pills, more precise prescribing is in order, say the authors of a new study titled, “State-level variation in opioid prescribing after knee arthroscopy among the opioid-naïve in the USA: 2015–2019,” was published in the August 20, 2020 edition of BMJ Open.
Swarm of unused opiods
Co-author Benjamin Ukert, M.D. is with the Department of Health Policy and Management at Texas A&M University System and the University of Pennsylvania.
Dr. Ukert told OSN, “The opioid epidemic has received a lot of attention and many state policies have been passed to address excessive opioid prescribing and highlight the dangers of opioid use for those who have never been exposed to opioids. We also now know that most patients with prescribed opioids for post-operative pain have significant quantities of pills leftover.”
“One study showed that after knee arthroscopy, 50% of patients took no opioids, and 90% took less than 5 pills (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7190545/). Thus, we asked the question whether we now observe low levels of prescribing following knee arthroscopy and whether there are differences in prescribing practices across states. The importance of different practice styles has been highlighted before, meaning that healthcare delivery differs by region, however there has been very little research examining prescribing following orthopedic procedures. Though it wasn’t clear to us how much variation one could expect to see for this common orthopedic procedure.”
The road to opioid stewardship
Pointing to national efforts at antibiotic stewardship as a model, the authors of this study have moved the needle on gathering baseline data to further the stewardship of opioids. Using commercial insurance data from 2015 and 2019, the investigators found 98,623 patients who were opioid-naïve and underwent a knee arthroscopy.
“Overall, 72% of patients filled an opioid prescription with a median tablet count of 40 and median morphine milligram equivalent of 250,” wrote the authors. “Patients with an invasive procedure (27.9% vs 22.4%), higher education level and fewer comorbidities (0.9 vs 1.2) had higher rates of opioid prescribing.”
Dr. Ukert: “We found wide variation in the rate of post-operative opioid prescribing for patients who were opioid-naïve undergoing knee arthroscopy and the dosage of the prescription across states, even after adjusting for patient characteristics. Over 70% of patients filled opioid prescriptions after surgery containing an average of 40 pills, significantly more than what patients have reported needing. We also found high tablet counts dispensed after the procedures for some states and much less for others. This is concerning, and somewhat surprising, given that the data covers 2015-2019, a period in which the negative effects of opioid initiation have been widely documented and publicized.”
Bordering states, wildly different prescribing patterns
“The biggest surprise,” said Dr. Ukert, “was the wide variation in opioid prescribing. In South Dakota about 40 out of every 100 patients received an opioid prescription whereas just over the border in Nebraska 85 out of every 100 patients received a prescription. we also found significant variation in the average number of opioid tablets prescribed, ranging from an average 24 tablets per prescription in Vermont to 45 tablets per prescription in Oklahoma. This is quite striking, indicating that practice patterns may play an important role.”
Small changes, big effects
“Given that emerging data show that many patients do not take prescribed opioids following knee arthroscopy, and if they do, most do well with 5 to 10 pills or less, there is a significant opportunity to reduce excessive prescribing,” continued Dr. Ukert. “In the very rare cases patients need more, refill prescriptions can now be extended electronically in most states. This minor change in workflow can take thousands of unused opioids from entering the community, reduce the likelihood of transition to long-term use and family member overdose.”
“It can help to set expectations pre-operatively and share with patients that most do well without opioids and or with a small amount and that using other medications such as acetaminophen and NSAIDs can be effective for managing pain after these procedures.”