Using Historical Variation in Opioid Prescribing Immediately After Fracture Surgery to Guide Maximum Initial Prescriptions

Abstract

Objectives: Recent studies have advocated for prescription opioid maximums (based on percentage reductions from historical amounts) to reduce excess prescribing. Implementing this in orthopaedic trauma has been difficult, given the injury variety and limited historical data on postoperative prescribing. We report on the initial opioid prescriptions for a large cohort of postoperative, opiate-naive fracture patients and hypothesize that prescribing was associated with fracture location and morphology.

Design: Retrospective cohort analysis.

Setting: Two American College of Surgeons Level I trauma centers.

Patients: Six thousand eight hundred seventy-nine orthopaedic trauma patients treated between 2002 and 2015. Only patients who had a single operatively treated injury and were opiate naive (had not received an opioid prescription in the 6 months before presentation) were included.

Intervention: Postoperative opioid discharge prescription.

Outcomes: We analyzed the quantity of initial opioids prescribed in morphine milligram equivalents (MMEs, a standardized unit of opioid dosage used for comparison across opioid types). Fracture location and morphology were classified using the OTA/AO classification.

Results: Fracture location was an independent predictor of the MME prescribed (P < 0.001). All other fracture locations were prescribed significantly higher MME than distal radius fractures (control group, 150 MME, P < 0.01). There was no difference in MMEs prescribed by articular involvement or degree of comminution.

Conclusions: We demonstrate significant variation in initial postoperative opioid prescribing to opiate-naive orthopaedic trauma patients by fracture location, but not by fracture morphology. We use these data to propose a guideline based on the OTA/AO fracture classification for the maximum initial prescription of opioids.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Conflict of interest statement

No conflicts of interest exist for any authors regarding this paper. One or more of the authors (MB) has received funding through a pre-doctoral Fellowship in Aging and Health Economics (NIA T32 AG 51108) from the National Institute on Aging. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging or the National Institutes of Health.

Figures

Figure 1:

Distribution of injuries among patients by fracture location portion of AO/OTA fracture classification

Figure 2:

(2a) Opioid Quantity (MME) by fracture morphology: extra-articular versus intra-articular for non-diaphyseal fractures; p=NS (2b) Opioid Quantity (MME) by diaphyseal fracture morphology: simple versus wedge versus complex; p=NS (NS=non-significant)

Figure 2:

(2a) Opioid Quantity (MME) by fracture morphology: extra-articular versus intra-articular for non-diaphyseal fractures; p=NS (2b) Opioid Quantity (MME) by diaphyseal fracture morphology: simple versus wedge versus complex; p=NS (NS=non-significant)