Sarasota, FL (WorkersCompensation.com) – This year has already been hard for the Orthopedic word, with many issues brought to the table, especially in regards to controlled substances. Earlier this month, Evangelos Megariotis, MD who owned and operated Clifton Orthopedics in New Jersey was charged with 34 counts of illegally prescribing narcotics.
In another case this month, orthopedic surgeon Mark Stephen Wilson, MD of Tulsa, Oklahoma agreed to settle for $343,000 to resolve allegations of illegal kickbacks in the form of “medical director fees” for prescribing compounded pain creams from 2014 to 2016. After that in 2020, Wilson was arrested for driving under the influence after he tested positive for controlled substances. Additionally, he was found with cocaine and admitted to regular use, according to a 2 News Oklahoma report. Subsequent action was taken with a 5-year agreement signed, but in July of last year disciplinary action was taken again for violation of the original agreement after he admitted to ingesting alcohol.
While the CDC has proposed new opioid new prescribing guidelines that adjust limits for chronic pain patients, and leaves more judgement to the physicians, a recent study published in the Journal of Orthopaedics highlights discrepancies in how opioids are prescribed. Considering recent criminal charges in the orthopedic world in an environment where guidelines are as strict as they ever have been, and monitoring of prescribing practices are under the microscope, one has to wonder where the new proposals will lead.
Orthopedic surgeons are the third highest opioid prescribers, totaling 11 percent of high volume prescriptions, with Hydrocodone and Oxycodone as the most common drug prescribed. Prescription patterns for common orthopedic surgeries such as total hip and knee vary greatly, with anywhere from 10 to 300 opioid pills after surgery, and many studies show as high as 80 percent of the pills prescribed are unused.
While some studies show patients who are given lower level of opioids at discharge result in less opioid use in the 30 days post-operative, other studies suggest the refill requests were higher among those patients who received small prescriptions at discharge.
The researchers from the Department of Orthopaedic Surgery at Massachusetts General Hospital studied 80 patients of which 33 were undergoing total hip arthroplasty, and 47 were undergoing total knee arthroplasty.
Prior to surgery, 1000 mg acetaminophen, 400mg celecoxib, and 50 mg pregabalin were given to the patients. Post operatively, the patients were given 975 mg oral acetaminophen every 8 hours, and 15 mg of ketorolac every 6 hours. If additional pain control was needed while the patients were admitted, the total knee patients received 5 to 10mg of oxycodone every 6 hours, and total hip patients received 50 to 100 mg of oral tramadol every 6 hours with additional oxycodone given if needed for pain.
Following discharge, patients were prescribed 5mg oxycodone or 50 mg tramadol. For those that could not take the oxycodone, they were prescribed 2mg hydromorphone or 5mg hydrocodone. Patients were given a pain medication journal to track their medication intake.
Overall, patients consumed less than half of their prescribed opioids. The patient took an average of 452 milliequivalents per litre (MEQ) in the post-operative period, yet only consumed 214 MEQ. The remaining 240 un-used MEQ is equivalent to 32 5mg oxycodone pills.
Overall, in the first week the opioid consumption was 123 MEQ, and dropped to half the second week at 60 MEQ. The total knee patients consumed more pain medication than the total hip patients, however both groups saw a decline in the first two weeks.
Total hip patients took 41 percent of their total prescriptions during days 1 to 3, and 77 percent of the total during the first week post-discharge. In comparison, total knee patients took 38 percent of their total prescriptions during the first 3 days post-discharge, and 70 percent during the first week. The average time period of reported opioid use was 14.5 days, with only 35 percent reporting use after that, most of which were total knee.
Only 15 percent of the total hip patients reported opioid use at 3 weeks after surgery. Comparatively, 50 percent of the total knee patients reported opioid use after 2 weeks, with 30 percent reporting use after 3 weeks, and 4 percent after 30 days.
Pain scores at the time of opioid use averaged 4.3 out of 10, with total knee patient also reporting higher levels of pain. The reported intensity of pain at the time of opioid consumption was higher than when Tylenol was used. An average 5 hours of pain relief was associated with opioid use. Nighttime use accounted for 52 percent of the opioid used.
Total opioid use after discharge increased 42.6 MEQ for each one point increase in pain score while they admitted. Overall, total knee patients consumed 176.1 MEQ more than total hip patients, anequivalent of 23.5 oxycodone 5 mg pills.