Comparing Opioid Prescription Patterns in Total Joint Arthroplasty Patients
Comparing Opioid Prescription Patterns in Total Joint Arthroplasty Patients
The United States constitutes <5% of the world's population but over 80% of the opioid supply
 and 99% of the hydrocodone supply. In 2014, there were 18,893 deaths from prescription drug
 overdose, and orthopaedic surgeons are the third highest prescribing physicians for opioids.
 Surgeons often prescribe opioids to minimize postoperative pain and to reduce the likelihood
 of readmission for pain. Available data suggests that orthopaedic surgeons are the most
 likely physicians to prescribe opioids to Medicare patients, whose opioid prescriptions are
 over 7 times more likely to come from an orthopaedic surgeon than another type of physician,
 but orthopaedic surgeons also had the highest readmission rate for post-operative pain. Many
 studies have investigated the utilization of opioids after surgery to assess surgeon's
 tendencies to overprescribe, demographics of those likely to overuse, and adverse events of
 opioid abusers.

 The primary purpose of this randomized controlled trial is to determine whether prescribing
 fewer opioid pills per prescription reduces the total amount of opioids taken, even while
 allowing equal total opioid availability via increased frequency of prescription
 availability.
A recent paper by Kim et al prospectively investigated opioid utilization after upper
 extremity surgery. This study (n=1,416) showed an opioid utilization rate of just 34%, taking
 an average 8.1 pills out of 24 prescribed. Patients age 30-39, those having joint procedures,
 upper extremity/shoulder surgery, or self-pay/Medicaid insurance were all far more likely to
 overuse opioids. The study concluded that their surgeons prescribed 3 times the required
 opioid following surgery and gave recommendations for opioid distribution based on location,
 procedure type, and patient risk factors. This study's identification of over prescription is
 congruent with a study completed by Bates et al that showed 67% of patients had a surplus of
 medications, with 92% not receiving proper medication disposal instructions.

 Other recent literature has attempted to risk stratify patients who are more likely to abuse
 prescription opioids. Morris et al identified various risk factors including: family history
 of substance abuse, nicotine dependency, age <45, psychiatric disorders, and lower level of
 education. These risk factors are associated with aberrant behaviors (non-compliance, early
 refill request, "lost or stolen" medication), which should raise concerns for any provider
 prescribing opioids.

 Studies have shown that patients who are on chronic opioid therapy before surgery have worse
 outcomes. Nicholas Bedard et al compared chronic opioids users (n= 35,068) versus those who
 were opioid-naïve at the time of total knee arthroplasty (TKA) and found the opioid group
 had more opioid scripts filled per patient at discharge as well as at 3, 6, and 9 months
 (0.63 scripts/patient vs. 1.2 scripts/patient, p<0.05). These patients also had a higher
 Charlson Comorbidity Index (p<0.05) and higher rates of respiratory failure, acute kidney
 failure, pneumonia, all post-operative infections, and infections requiring return to the OR.
 The study concluded patients should have their opioid consumption controlled during the
 pre-operative and peri-operative period.

 In addition to the complications of opioid medications experienced by orthopaedic patients, a
 recent nationwide retrospective analysis presents an unintended yet severe problem associated
 with opioid prescriptions. The incidence of pediatric hospitalizations for opioid toxicity
 nearly tripled from 1997 to 2012. The over-prescription of opioids creates a readily
 available source for accidental ingestion by younger children and for intentional opioid
 overdose by older pediatric/adolescent patients. In fact, a family member's leftover pills
 have been described as the number one source for pediatric opioid overdose. Moreover, the
 Center for Disease Control reported that in 2015 the U.S. saw its highest incidence of
 opioid-related death.9 Given the frequency and severity of opioid diversion and misuse,
 orthopaedic surgeons should consider the best methods for controlling patients postoperative
 pain and also avoid facilitating opiate misuse, whether by orthopaedic patients or other
 community members. With this goal in mind, our study will investigate regimens for effective
 postoperative pain control that also minimize the total amount of opioids prescribed.
Inclusion Criteria:

 -  any patient > 18 years of age scheduled for primary total hip or knee arthroplasty who
 is not consuming opioids during the 4 weeks prior to surgery

 Exclusion Criteria:

 -  patients consuming opioids during the 4 weeks prior to surgery

 -  patients who are allergic to oxycodone or refuse to take oxycodone

 -  patients with a history of opioid dependence or illegal or "off-label" opioid use

 -  patients undergoing a revision total knee or total hip arthroplasty

 -  any patient less than 18 years of age