By Melissa Young Szalay, MD

The Hand Surgery section of my Orthopaedic group has been in front of the curve in terms of addressing potential over-prescribing of opioids after surgery. My partner, Dr. Jeffrey Rodgers, was a co-author of a study that evaluated postoperative pain control and quantified the amount of leftover pain medication (“Opioid consumption following outpatient upper extremity surgery,” JHS, 2012 Apr). The results showed that 92% of patients reported adequate pain control, and there was a significant number of pills not taken (4639 leftover tablets for the cohort of 250 patients), concluding that excess opioid analgesics were made available after elective upper extremity surgery.  These findings prompted our Hand Surgery section to create guidelines for prescribing opioids after common hand procedures.  Additionally, we made it “office policy” that patients could receive a maximum of 30 pills for soft tissue procedures and 60 pills for bony procedures.  This was helpful when patients would request additional pain medication, citing the office policy as the reason for not prescribing more.  I had always felt that I was very conservative in my pain medication prescribing practices, but after learning the results of this study, I made fairly significant reductions in what I was prescribing, with no measurable increase in phone calls from patients complaining of inadequate pain control.

More recently, Dr. Rodgers spearheaded a QI study within our surgery center to look at prescribing practices of 15 surgeons, before and after the surgeons received 2 articles to review on the subject of opioid prescribing (including the article mentioned above and below) and a request to reduce quantities prescribed and to consider sequential prescriptions. Sequential prescriptions can be given at the time of surgery, with the 2^nd prescription stating, “do not fill until 2 days after issuance.”  Specific recommendations were given for seven procedures, using the minimum number of hydrocodone 5/325 equivalents prescribed that were observed in the baseline “before” data for a given procedure.  As it pertains to hand surgery, the following recommendations were made: CMC arthroplasty, HC 5/325 #15/15; CTR, HC 5/325 #10/no 2^nd prescription; ORIF distal radius fracture, HC 5/325 #15/15.  Follow up data analysis focused on 5 procedures initially showing the greatest prescribing variability; post-education prescribing practices revealed reductions in medications dispensed in 4 of the 5 procedures. Additionally, 47% sequential prescriptions were being given, compared to 13% in the initial data.  This internal study emphasizes the value of education regarding opioid prescribing practices, as well as the potential benefit of establishing a uniform policy for prescribing.  We can learn from our partners who prescribe less medication, and feel empowered to change our prescribing patterns without sacrificing patient care.

Finally, there is data to support that the length of time (duration) an opioid is taken dramatically increases the risk of addiction, with nearly a linear curve (“Postsurgical prescriptions for opioid naïve patients and association with overdose and misuse,” BMJ, 2018 Jan).  Based on the results of this study, I now counsel my patients and their families that I expect them to be off of opioids by 3 days post op.  This sets expectations ahead of time that they should not need prescription pain medication for any longer than this.

I encourage everyone to critically assess your own prescribing practices, and compare to your colleagues. I hope that you also conclude that fewer leftover pills (that could be misused by someone else) and fewer days on an opioid is good for everyone!