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Orthopaedic Surgeon and Primary Care Provider Perceptions of Pain Management Relating to Common Orthopaedic Conditions

Jeffrey R. Jaglowski M.D., M.S., Stephane Bergeron, M.D., Mark Vrahas, M.D.

Use and abuse of opioid pain medications had dramatically increased over the past 20 years. Studies have identified Orthopaedic Surgeons and Primary Care Providers (PCP) as major prescribers of these drugs. Given that these specialties often share patients, we examined the perception of pain control by each specialty in relation to common orthopaedic conditions treated both operatively and non-operatively. Orthopaedic Surgeons rely heavily on PCP follow up and guidance after orthopaedic procedures.

To identify large gaps in therapy for orthopaedic conditions between the two specialties in an effort to further regulate opioid prescribing to improve patient care. This may eventually lead to the creation of treatment protocols to prevent the abuse of prescription opioids at our institution. Secondary objectives of our study were to determine surgeon/PCP factors that guide and limit narcotic prescription habits as well as examine variances in type of pain medication prescribed.

A validated questionnaire to examine the above objectives was created. This survey was submitted to members of the Harvard Combined Orthopaedic Surgery Program and Partners Healthcare System including all Orthopaedic Surgeons, Residents, and Fellows. Response rate among this population was 46%. A similar but slightly modified version of the survey was also distributed to Primary Care Providers and their associated Residents/Fellows within the same system. Response rate among this population was 21%. Main questioning involved how long respondents would anticipate a patient to require opioids for a certain condition vs. the length of time until the respondent would actually cease to provide an opioid prescription to a patient. Scenarios had both non-operative and operative conditions addressed.

Using a billing registry at our institution, we determined the number of TKAs performed from 2000 to 2011. Of those, we determined which had undergone a reoperation within sixty days. We evaluated those that had immediate postoperative radiographs following their primary TKA, and determined those that had been reoperated on as a result of information obtained from these films.

Outcomes were reported for each scenario in each group individually. Outcomes were also compared between the two groups. Statistical analyses were constructed (2 sample T-test) to compare several means both within and between the population groups.
Results are reported in terms of days and statistical values are reported from the 2 sample T-tests with P values conveyed where applicable.

For all 4 scenarios, Orthopaedic Surgeons will prescribe opioids longer than what they anticipate the need will be both pre-op and post-op (P<0.00001). This was also the case for PCPs (with exception of non-operative therapy for hip OA). No significant differences were observed between anticipated duration pre-operatively, ceasing opioids pre-operatively, or anticipated duration post-operatively between surgeons/PCPs in all 4 scenarios. There was however a significant difference (P<0.001) between surgeons and PCPs in relation to ceasing opioids post-operatively (a significantly longer time would pass before surgeons would stop prescribing opioids as compared to PCPs post operatively). PCPs were more likely to prescribe a lower potency opioid or a non-steroidal anti-inflammatory drug (NSAID) compared to surgeons in all four scenarios.

There are obvious differences among these two specialties regarding the prescribing of pain medication. Between both groups in all four scenarios, there was a statistical difference between how long a physician would anticipate the need for opioids and how long before a physician would actually cease to provide an opioid prescription both pre-operatively and post-operatively. Why pain medication would be prescribed longer than anticipated (barring patient specific factors or operative complication) still needs to be determined. This demonstrates the lack of an official protocol when prescribing pain medication and can lead to over prescribing. Given the fact that PCPs will often prescribe lower potency opioids, have a tendency to use NSAIDs more frequently, and would also prescribe opioids for a statistically significant less time than surgeons post-operatively, it might be advantageous to involve the PCP in decision making early in the process or even pre-operatively. This would lead to safer prescribing practices and ultimately better patient care through communication.