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

Abstract

Background: The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context. Methods: Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. Results: U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019). Conclusions: Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma. Clinical Relevance: Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis. M usculoskeletal injuries are responsible for a large global burden of preventable injuries, disability, and death 1,2. In the U.S., opioid prescribing for such conditions is currently considered problematic and appears to be a major factor contributing to what is considered an opioid epidemic by bodies such as the Centers for Disease Control and Prevention (CDC) 3-5. Over the past 20 years, U.S. opioid prescriptions and opioid-related deaths have increased greatly 5. U.S. physicians and policymakers have attempted to address the opioid crisis by curtailing the freq...

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

“…We found that anatomic location did not impact nonopioid prescribing (Table 4 ). A previous analysis conducted by this group demonstrated differential opioid prescribing for cases of orthopaedic trauma based on anatomic location, 11 but the reasons why such a differential prescribing pattern does not hold true for nonopioids remain unclear. Previous studies have suggested the possibility of dose efficacy for nonopioids in pain management, although nonopioid-dose response has not been directly studied within an orthopaedic context.…”

“…Previous work has demonstrated significant variation in opioid prescribing between countries, with US providers prescribing opioids more commonly and at higher doses. 10 , 11 To better contextualize US opioid prescribing, this study sought to examine how nonopioid prescribing varies between countries in total quantity, duration, and coprescription with opioid medications. Our study demonstrates clinically relevant differences in nonopioid and multimodal analgesic prescribing between the United States, Haiti, and the Netherlands.…”

“…This finding may at least partly explain the findings from our previous study which indicated higher opioid doses and prescription durations prescribed among the US residents for postoperative analgesia. 10 , 11 Prescribing opioid monotherapy is not without risks because previous work has noted an increased likelihood of adverse events associated with higher levels of opioid exposure. 36 In addition, recent work has indicated that opioids may also limit bone healing and callus formation and thus raise concern for opioid use at high doses or for prolonged durations.…”

“…The methodology for this study has previously been published. 11 In brief, we surveyed orthopaedic residents from nine academic residency programs in three countries (the United States, the Netherlands, and Haiti) between April and November 2017, using a set of 10 musculoskeletal trauma vignettes (SDC 1, http://links.lww.com/JG9/A76 ). We chose to focus on residents because they are the primary postoperative analgesic prescribers at academic centers and thus enable us to more accurately evaluate prescribing patterns in academic clinical practice.…”

“…For example, we recently demonstrated how opioid prescribing varies significantly between countries, with US providers prescribing opioids more frequently and at higher dosages than prescribers in the Netherlands and Haiti. 10 , 11 Yet, that work was limited to opioid prescriptions, and there are few quantitative comparative studies of international postoperative nonopioid prescribing patterns. 7 …”