Advanced practice clinicians prescribe higher total opioid dosages vs. surgeons
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Although surgeons wrote the most perioperative opioid prescriptions after surgery, published results showed advanced practice clinicians prescribed higher total opioid dosages.
“Compared with surgeons, advanced practice clinicians provided larger perioperative opioid prescriptions — a difference equivalent to about eight pills of 5 mg hydrocodone,” Kao-Ping Chua, MD, PhD, told Healio.
Using Optum’s De-Identified Clinformatics Data Mart, Chua and colleagues identified 581,387 patients who underwent 628,197 surgical procedures from Jan. 1, 2017, through Nov. 30, 2019, and received one or more perioperative opioid prescription. With the outcome defined as the proportion of perioperative opioid prescriptions and refill prescriptions written by advanced practice clinicians (APCs), researchers used linear regression to compare the total dosage of perioperative opioid prescriptions by APCs vs. surgeons measured in morphine milligram equivalents. Researchers adjusted models for demographic characteristics, comorbidities, opioid-naïve status, year of index date, hospitalization or observation status, surgical complications and surgeon specialty.
Results showed APCs wrote 19% of the 628,197 perioperative opioid prescriptions compared with surgeons who wrote 73.1% and other prescribers who wrote 7.9%. Among perioperative opioid prescriptions, researchers noted APCs had a mean total dosage of 362.4 morphine milligram equivalents compared with 260.2 morphine milligram equivalents from surgeons. Researchers also found a mean daily dosage of 51.3 morphine milligram equivalents from APCs and 44.5 morphine milligram equivalents from surgeons.
Of the 237,740 refill prescriptions, researchers found APCs wrote 25.1%, surgeons wrote 52.5% and other prescribers wrote 22.4%. APCs had a mean total dosage of 525.5 morphine milligram equivalents among first refill prescriptions vs. 353.7 morphine milligram equivalents from surgeons, according to results. Researchers noted APCs had a mean daily dosage of 52.4 morphine milligram equivalents compared with 46.1 morphine milligram equivalents from surgeons.
Researchers found APCs wrote a higher proportion of perioperative opioid prescriptions when the procedures were for older patients or for patients residing in the Northeast. Adjusted models showed older age, commercial insurance, residency outside of the South, urban residency, year of index date beyond 2017, admission to observation or the hospital, and surgeon specialty were associated with receiving a perioperative opioid prescription from APCs.
“Our findings highlight the crucial role of advanced practice clinicians in the care of surgical patients and demonstrate the need for developing opioid stewardship initiatives for advanced practice clinicians as they continue to become a larger part of surgical care teams,” Chua said.
Perspective
Back to TopSommer Hammoud, MD, and William L. Johns, MD
This study highlights the need for opioid stewardship initiatives focused on APCs. Most studies and initiatives to date in orthopedic surgery have focused on the attending surgeons. This current study brings to the forefront that APCs are prescribing one-fifth of total opioids and 25% of refills postoperatively. Moreover, orthopedics ranks No. 1 in total surgical procedures by subspeciality and second in mean adjusted morphine milligram equivalents per procedure, with APCs prescribing nearly 30% of those opioids. These numbers are particularly alarming because we have found through our own research at the Rothman Institute that the majority of postoperative opioids being prescribed after select outpatient orthopedic procedures are not being used. A large proportion of unused opioids are being disposed of inappropriately or saved for future use, a risk factor for misuse and divergence of opioids into the community. Through continued research and further emphasis on perioperative regional anesthetic techniques, multimodal pain management and patient education, we can continue to move the needle and combat the opioid crisis. The authors are commended for their critical evaluation of a challenging topic faced by many surgical subspecialities. These study findings underscore the responsibility and opportunity for surgeons and APCs, particularly in orthopedics, to lead the initiative toward combating the nationwide opioid epidemic.
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