Orthopedic Surgeon Decision-Making Processes for Postsurgical Opioid Prescribing

Acute pain and chronic pain are significant burdens in the Department of Defense, compounded by the ongoing opioid crisis. Given the ubiquity of (leftover) opioid prescriptions following orthopedic surgery, it is essential to identify feasible and acceptable avenues of opioid risk mitigation efforts. The present quality improvement project builds on recent studies by evaluating factors related to opioid prescribing decisions in a sample of orthopedic surgery providers.

This quality improvement project received a Determination of Not Research and was conducted through a collaboration between the Department of Orthopaedic Surgery and the Department of Anesthesiology and Pain Management at Walter Reed National Military Medical Center. Providers in the Department of Orthopaedic Surgery completed an anonymous online survey assessing opioid prescribing education, factors influencing prescribing practices, opioid-safety practices, and perspectives on potential opioid safety initiatives.

In total, 39 respondents completed surveys. There was variability in exposure to different types of opioid prescribing education, with some variation between attendings/physician assistants and residents. Patients' acute postsurgical pain, using a standardized amount for most patients, and prescription histories were the three most influential factors. Concern of patients running out and fear of patient dissatisfaction were the least influential factors. Respondents commonly reported engagement in promoting nonpharmacological pain management, as well as coordinating with chronic pain providers when applicable, but did not commonly report educating patients on leftover opioid disposal. Respondents indicated that a barrier to opioid risk mitigation was the difficulty of accessing appropriate electronic health record data to inform decisions. Lastly, they reported openness to proposed opioid safety initiatives.

The results of this quality improvement project identified several target areas for future initiatives focused on improving opioid prescribing practices. This included a provider training program, improved patient education system, increased awareness and use of opioid tracking databases, and development of a standardized (but adaptable per patient characteristics and history) recommended dose for common orthopedic surgeries. Future projects will target tailored development, implementation, and evaluation of such efforts.