As doctors consider their role in the nation's opioid epidemic, much attention has been paid to primary care physicians, who account for fully half of the prescription opioids dispensed.
But orthopedic surgeons — who rank third, behind internists, when it comes to writing opioid prescriptions — have also been attuned to the crisis. A new study of prescribing habits on the athenahealth network found that orthopedic surgeons nationwide have significantly dropped their opioid prescribing over the past three years: a relative decrease of 13.4 percent from early 2014 to early 2017.
It wasn't a steady decline. Over that three-year period, there were small fluctuations in the length and intensity of prescriptions, with slight increases in the fourth quarters of 2015 and 2016 — often the busiest times of year for orthopedic surgery.
Still, the data suggest that orthopedic surgeons are changing their procedures, and their communication with patients, in response to a national problem.
The analysis looked at about 800 orthopedic surgeons, treating 370,000 patients across the network every quarter between 2014 and 2017. Despite the fluctuations, the average day supply per prescription remained flat, at about 51-55 days. And the share of high-strength prescriptions — of more than 90 morphine milligram equivalents, or MME, per day — was very small, accounting for only 2.3 percent of prescriptions as of the first quarter in 2017.
Primary care providers, by contrast, prescribe an average of four times the share of high-strength prescriptions, and offer day-supply rates that are 1.5 times longer, athenahealth data show.
This could be because primary care physicians receive the majority of marketing from pharmaceutical companies, says David Ring, M.D., a hand surgeon and chair of the committee of patient safety at the American Academy of Orthopaedic Surgeons.
“Some orthopedic surgeons will refuse to give patients more opioids, so then [patients] go to their primary care provider and ask for a prescription," Ring says. “That's the doctor they see more often and can be more comfortable with, so it makes sense. And if the primary care doctor isn't aware of the scope of the situation, you can run into problems."
A message in the data
Opioid prescribing rates vary across specialties, but athenahealth data show they have been declining across the board: 12.6 percent across all specialty groups since 2014. Among primary care physicians during that time, opioid prescribing rates decreased by 15.7 percent. Among all the specialties, orthopedics had the second-largest relative decrease: 13.4 percent.
For physicians in the field, changing prescribing habits often takes deliberate steps — and a data-driven approach.
Leaders of OSS Health, an orthopedic surgery group that sees 250,000 patients in York County, Pennsylvania, wanted to examine their role in the region's opioid crisis after a spike in local deaths was attributed to a combination of prescription pills, heroin, and cocaine.
Suzette Song, M.D., an orthopedic surgeon and partner at OSSHealth, said the data they uncovered were shocking. In 2015, OSS Health patients went home with 18,000 prescriptions a year for opioid painkillers, adding up to approximately 800,000 pills.
“We thought we might be better than average because we were conscientious in prescribing, but the numbers were massive," she says. “We wondered how bad other rates were."
OSS Health launched a comprehensive, multi-step plan to decrease the number of pills its providers prescribed. They began by prescribing fewer pills for the 10 highest volume surgeries, going from 120 pills for a knee replacement to 90, then ultimately down to 60.
Setting expectations for pain
Song said it was important to standardize the approach — and to educate both patients and physicians. Because OSS Health has high patient experience scores, some surgeons expressed concern that patients would get angry if they were prescribed fewer pills.
But everyone, from the nurses on the floor to the surgeons, worked together to warn patients that they would experience discomfort — and to explain that when it was an appropriate time to be weaned off pain management pills, they wouldn't get a refill.
Surveys have shown that some surgeons prescribe opioids because they are concerned about patient antagonism or dissatisfaction, says Ring of the American Academy of Orthopaedic Surgeons. Instead, he says, physicians need to send the message that pain is a part of life, and start normalizing resiliency.
“Most of the world treats pain without opioids," he says. “But in America, there seems to be a mindset that says, 'We're industrious people. If we do the right thing or pay the right person, we won't be in pain.'"
Song says that when patients were well-informed, they accepted the new standards.
“We got less people asking for more pills than we feared we would, and we attribute that to setting appropriate expectations, so people felt less anxious about not getting a prescription on their next visit," Song says. “It helped people get over their fear of change."
The results have paid off. By the end of 2016, OSS Health had dispensed 220,000 fewer opioid prescriptions than the year before, decreasing its total prescriptions by 15 percent compared to the end of 2015, even though the number of patients increased in that time.
And compared to the year before, the practice saw a 24 percent reduction in hydrocodone prescriptions, and a 45 percent decrease in the number of pills prescribed.
“We wanted a dramatic improvement, not a little improvement," Song says. “But even if a practice makes one change, whether it's giving fewer pills for one procedure or managing expectations, the situation can improve. In the end, better is better, in whatever way you can get there."
Allison Pohle is a writer based in Boston.