Orthopedics

Feature Article 

Postdischarge Opiate-Prescribing Habits for Primary THA and TKA: A Survey of American Association of Hip and Knee Surgeons Members

Jason S. Lipof, MD; Caroline P. Thirukumaran, MBBS, MHA, PhD; Alexander S. Greenstein, MD; Zachary Zmich, MD; Alexander Lander, BSE; Benjamin F. Ricciardi, MD

Abstract

Abuse of opiate medications has reached epidemic proportions, and elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) typically require outpatient use of narcotic medications. This survey sought to determine opiate-prescribing habits of members of the American Association of Hip and Knee Surgeons (AAHKS) for patients undergoing primary THA and TKA. An 11-question online survey was developed to evaluate current prescribing habits for opiate and nonopiate medications prescribed after primary THA and TKA. An invitation to complete the survey was e-mailed to 2698 orthopedic surgeons using an AAHKS listserv. Surgeons' demographic information and their prescribing habits of opiate and nonopiate medications postdischarge were recorded. Data were examined using descriptive statistics, chi-square, and multivariate logistic regression. Responses were received from 325 of 2698 (12.1%) AAHKS members. Significant variation in the type of opiate prescribed and the number of pills dispensed was observed. Higher surgical volume and less years in surgical practice were associated with a higher number of opiate pills prescribed after THA and TKA. There were no statistically significant associations between opiates prescribed and use of an ambulatory surgery center or presence of departmental guidelines. Although THA and TKA are relatively standardized procedures performed nationwide, significant variability exists among surgeons regarding postdischarge opiate- and nonopiate-prescribing habits. There is a need for greater standardization to create a unified, evidence-based, and safe regimen for the postoperative period while reducing the opiate burden in the surrounding community. [Orthopedics. 2019; 42(6):361–367.]

Abstract

Abuse of opiate medications has reached epidemic proportions, and elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) typically require outpatient use of narcotic medications. This survey sought to determine opiate-prescribing habits of members of the American Association of Hip and Knee Surgeons (AAHKS) for patients undergoing primary THA and TKA. An 11-question online survey was developed to evaluate current prescribing habits for opiate and nonopiate medications prescribed after primary THA and TKA. An invitation to complete the survey was e-mailed to 2698 orthopedic surgeons using an AAHKS listserv. Surgeons' demographic information and their prescribing habits of opiate and nonopiate medications postdischarge were recorded. Data were examined using descriptive statistics, chi-square, and multivariate logistic regression. Responses were received from 325 of 2698 (12.1%) AAHKS members. Significant variation in the type of opiate prescribed and the number of pills dispensed was observed. Higher surgical volume and less years in surgical practice were associated with a higher number of opiate pills prescribed after THA and TKA. There were no statistically significant associations between opiates prescribed and use of an ambulatory surgery center or presence of departmental guidelines. Although THA and TKA are relatively standardized procedures performed nationwide, significant variability exists among surgeons regarding postdischarge opiate- and nonopiate-prescribing habits. There is a need for greater standardization to create a unified, evidence-based, and safe regimen for the postoperative period while reducing the opiate burden in the surrounding community. [Orthopedics. 2019; 42(6):361–367.]

The abuse of opiate medications in the United States has reached epidemic proportions. The United States reportedly consumes 99% of the world's hydrocodone and 83% of the world's oxycodone supply.1,2 In 2010, more than 16,000 deaths were caused by narcotic overdose; this amounts to 115 deaths per day, with 46 deaths being directly related to prescription opiates.3,4 Orthopedic surgeons are 1 of the top 3 prescribers of narcotic pain medications in the United States, and prescription of these medications recently has come under scrutiny.2

The number of patients undergoing primary total hip (THA) and total knee arthroplasty (TKA) continues to increase, and this leads to increased opiate prescribing by orthopedic surgeons.5 In addition, decreased inpatient length of stay and increased use of ambulatory surgery centers (ASCs) after primary THA and TKA has shifted a greater proportion of the perioperative pain management burden to the outpatient setting.6–9

Although some states have tried to institute greater control of ambulatory narcotic prescribing, data on the prescribing habits of clinicians in the elective surgery setting are sparse.10 The amount of opiate and non-opiate pain medications prescribed after primary THA and TKA is provider dependent, and established guidelines traditionally have not been used. Understanding the variation in the pain medication-prescribing habits at a national level among surgeons performing primary THA and TKA may help create evidence-based guidelines to reduce opiate burden in the community while providing optimal pain management to patients in the outpatient setting.

The current study was undertaken to survey the opiate and nonopiate-prescribing habits of members of the American Association of Hip and Knee Surgeons (AAHKS) after patient discharge following primary THA and TKA, with the aim of understanding the level of variation among ambulatory pain medication prescriptions in this setting. The authors hypothesized that significant variation exists at a national level regarding opiate-prescribing habits among orthopedic surgeons performing primary THA and TKA. To the authors' knowledge, this is the first national survey of pain medication-prescribing habits of experts in primary THA and TKA.

Materials and Methods

Survey Development

An online questionnaire was developed using SurveyMonkey to evaluate current prescribing habits for opiate and nonopiate pain medications prescribed at discharge following primary THA and TKA. Eleven questions regarding ambulatory pain medication-prescribing habits were included (Table 1). The goal of the survey was to identify the specific type of opioid and nonopioid medications prescribed at discharge, the number of pills dispensed in the initial prescription, surgeon demographic information (geographic location, years in practice, and surgical volume), and whether any guidelines for prescribing pain medication existed at the surgeons' institution. Primary THA and TKA were evaluated separately, and revision THA and TKA were excluded. Because the focus of the study was oral medications prescribed after surgery, neither the type of anesthetic nor the use of periarticular injections were evaluated. The tendency to provide medication refills to patients also was not evaluated.

Survey Questions on Prescribing Habits of Opiate and Nonopiate Pain Medications

Table 1:

Survey Questions on Prescribing Habits of Opiate and Nonopiate Pain Medications

The survey was reviewed by the AAHKS research committee and was approved for distribution to its members. An invitation to participate in this deidentified/anonymous survey was e-mailed via a listserv to 2698 orthopedic surgeons who were AAHKS members. This study was exempt from institutional review board approval because it was an anonymous, voluntary survey and did not use any patient-identifying data.

Survey Data

Surgeon information included location of practice (by state), number of years in practice, surgical volume based on total number of primary THA and TKA surgeries performed, use of an ASC, and presence or absence of departmental opiate-prescribing guidelines (Table 1). The number of pills and the type of opiate and nonopiate medications prescribed at discharge after primary THA and TKA were surveyed separately.

The opioids included in this study were Ultram (tramadol), oxycodone, Percocet (oxycodone and acetaminophen), Vicodin (hydrocodone and acetaminophen), Norco (hydrocodone and acetaminophen), Tylenol No. 3 (codeine and acetaminophen), Dilaudid (hydromorphone), OxyContin (long-acting oxycodone), and MS Contin (long-acting morphine). Additional non-narcotic pain medications included Advil (ibuprofen), Aleve (naproxen), Mobic (meloxicam), other nonsteroidal anti-inflammatory drugs (NSAIDs), Tylenol (acetaminophen), Lyrica (pregabalin), gabapentin, duloxetine, and other medications not listed.

Surgeon location was divided regionally into Northeast, Midwest, South, and West in accordance with US Census Bureau regional divisions.11 The number of narcotic pills prescribed was identified.

Statistical Analysis

Because the survey questions had categorical response choices, proportions of the categories for univariate/descriptive analysis were calculated first. For bivariate analyses, chi-square tests were used to examine the unadjusted variation in prescribing practices across surgeon and practice/facility characteristics; P<.05 was used to assess significance. The key outcome of interest was the number of pills prescribed at discharge, which were divided into low (≤60 pills) and high (>60 pills) categories for this analysis.

For the multivariate analysis, hierarchical logistic regression models were estimated to examine the association between the primary outcome (the number of pills prescribed at discharge) and key predictors that explained the variation in the outcome. The predictors used included years of experience (≤10 years, 11 to 20 years, and ≥21 years), annual joint replacement volume (≤200 surgeries, 201 to 400 surgeries, and >400 surgeries), availability of opioid guidelines in the hospital (yes/no), joint replacements performed in ASCs (most, less than half, none), and whether other pain medications were prescribed at discharge (yes/no). Geographic variation in practice patterns also was accounted for by controlling for state random effects; adjusted odds ratios were reported for these multivariate models. Adjusted marginal estimates also were calculated for key variables that represent the adjusted probability of prescribing a greater number of narcotic pills (>61) at discharge.

All analyses were conducted using Stata/MP version 14.2 (Stata Corp, College Station, Texas). Estimates with P<.05 were considered statistically significant.

Results

A total of 325 responses were received from 2698 AAHKS members, resulting in a survey response rate of 12%. The characteristics of surgeons who responded to the survey are provided in Table 2. Of the participants, 26% (n=85) were in the Midwest, 18% (n=58) were in the Northeast, 39% (n=125) were in the South, and 18% (n=57) were in the West. One-fourth of survey respondents (25%) performed between 201 and 300 combined THA and TKA annually. A total of 22% of respondents used ASCs to perform total joint arthroplasty, and the remaining 78% did not. Thirty percent of respondents reported having departmental or service-level guidelines for postoperative opiate prescribing, whereas almost 70% did not have such guidelines (Table 2).

Respondent Demographics

Table 2:

Respondent Demographics

Regarding THA, 23% of respondents prescribed less than 40 narcotic pain pills at discharge, 53% prescribed 41 to 80 pills, and 24% prescribed more than 80 pills at discharge (Table 3). Twenty percent of respondents used multimodal analgesia involving Lyrica, gabapentin, or duloxetine. Fifteen percent of respondents prescribed long-acting opiates in addition to short-acting opiates, and 98% prescribed short-acting opiates after THA.

Opioid- and Nonopioid-Prescribing Habits of Pain Medication After Primary THA

Table 3:

Opioid- and Nonopioid-Prescribing Habits of Pain Medication After Primary THA

Regarding TKA, 18% of respondents prescribed less than 40 narcotic pain pills at discharge, 50% prescribed 41 to 80 pills, and 31% prescribed more than 80 pills at discharge (Table 4). Twenty-two percent of respondents used multimodal analgesia involving Lyrica, gabapentin, or duloxetine. Seventeen percent of respondents prescribed long-acting opiates in addition to short-acting opiates, and 99% prescribed short-acting opiates.

Opioid- and Nonopioid-Prescribing Habits of Pain Medication After Primary TKA

Table 4:

Opioid- and Nonopioid-Prescribing Habits of Pain Medication After Primary TKA

For the bivariate analysis, after primary THA, surgeon years in practice was associated with the number of narcotic pills prescribed (P=.05) (Table 5). No statistically significant association was found between the number of narcotic pills prescribed and the annual volume of THAs performed, use of nonopiate medication at discharge, use of an ASC, or the presence of departmental guidelines for opiate prescribing. After primary TKA, annual surgical volume was associated with the number of narcotic pills prescribed (P<.01) (Table 6). No statistically significant association was found between the number of narcotic pills prescribed and the surgeon years in practice, use of nonopiate medication at discharge, use of an ASC, or the presence of departmental guidelines for opiate prescribing.

Association Between Opiates Prescribed and Selected Surgeon Demographics After THA

Table 5:

Association Between Opiates Prescribed and Selected Surgeon Demographics After THA

Association Between Opiates Prescribed and Selected Surgeon Demographics After TKA

Table 6:

Association Between Opiates Prescribed and Selected Surgeon Demographics After TKA

For the multivariate analyses (Table 7), after primary THA, surgeons with more than 11 years of experience were less likely to prescribe a higher number of pills at discharge compared with surgeons with 10 or fewer years of experience. For surgeons with 11 to 20 years of experience, the adjusted odds ratio (AOR) was 0.33 (95% confidence interval [CI], 0.15 to 0.70; P=.004). For surgeons with more than 21 years of experience, the AOR was 0.34 (95% CI, 0.17 to 0.68; P=.002). Of importance, surgeons performing more than 400 joint replacements annually were more likely to prescribe a higher number of pills than surgeons performing fewer than 200 surgeries annually (AOR, 2.36; 95% CI, 1.08 to 5.13; P=.03).

Multivariate Estimates of the Association Between the Number of Narcotic Pills Prescribed and Surgeon and Practice Demographics

Table 7:

Multivariate Estimates of the Association Between the Number of Narcotic Pills Prescribed and Surgeon and Practice Demographics

Similarly, after primary TKA, surgeons with more years of experience were likely to prescribe fewer narcotic pills compared with surgeons with 10 or fewer years of experience. For surgeons with 11 to 20 years of experience, the AOR was 0.35 (95% CI, 0.16 to 0.75; P=.007). For surgeons with more than 21 years of experience, the AOR was 0.37 (95% CI, 0.18 to 0.76; P=.006). In addition, high-volume surgeons were more likely to prescribe more pills than surgeons who performed less than 200 surgeries annually (AOR, 3.73; 95% CI, 1.74 to 7.98; P=.001).

The adjusted marginal estimates indicate that after primary THA, the likelihood of prescribing 61 or more pills at discharge was 58.06% for surgeons with 10 or fewer years of experience, 35.34% for surgeons with 11 to 20 years of experience, and 35.77% for surgeons with more than 21 years. The likelihood of prescribing 61 or more pills was 30.36% for surgeons performing 200 or fewer surgeries annually, 39.84% for surgeons performing 201 to 400 surgeries, and 46.89% for surgeons performing more than 400 surgeries. After primary TKA, the likelihood of prescribing 61 or more pills at discharge was 61.04% for surgeons with 10 or fewer years of experience, 39.92% for surgeons with 11 to 20 years of experience, and 41.30% for surgeons with more than 21 years of experience. The likelihood of prescribing 61 or more pills was 32.21% for surgeons performing 200 or fewer surgeries each year, 41.04% for surgeons performing 201 to 400 surgeries, and 58.54% for surgeons performing more than 400 surgeries.

Discussion

In this study, AAHKS members were surveyed to assess opiate-prescribing patterns after primary THA and TKA in the United States. This is the first national survey of orthopedic surgeons performing primary THA and TKA to examine opiate- and nonopiate-prescribing habits post-discharge. The results revealed substantial variation in opiate- and nonopiate-prescribing patterns during the early postoperative period for primary THA and TKA despite these surgeries being performed in a relatively standardized manner across the country. In addition, there is a lack of departmental or service-based guidelines for postoperative pain in the majority of institutions. The multivariate analysis showed an association between fewer years in practice and higher surgical volumes with an increased number of narcotic pills prescribed for primary THA and TKA. These results show there is a substantial opportunity to improve standardization of outpatient opiate and multimodal pain medication prescribing habits at the national level.

The abuse of opiate medications in the United States has reached epidemic proportions, and the total amount of opiate medications prescribed has increased from 96 mg per person in 1997 to 700 mg per person in 2007, a 600% increase.12,13 Sufficient treatment of postoperative pain is associated with improved patient satisfaction scores, which have been used to create financial incentives at the institutional level, and increased participation in postoperative rehabilitation.14,15

In contrast to the benefits of narcotic pain medication, the unintended consequences of these regimens are not without significant cost. The health-related, societal, and financial cost burden of the current opiate epidemic is weighty. Between 2000 and 2014, the rate of opioid-related overdose deaths increased by 200%.16 Prescription opiates and heroin were associated with 61% of all drug overdose deaths reported in 2014, which is a 3-fold increase compared with the year 2000. This increase parallels the rate of misuse of and dependence on prescription opiate medications in the United States. Orthopedic surgeons are responsible for a significant proportion of outpatient pain medication prescriptions. The variation in prescribing habits in the current survey suggests the pill burden in the community may be highly variable if patients do not use the majority of their prescribed narcotics.

This survey showed significant variation in the number of pills prescribed post-discharge after primary THA and TKA, with more inexperienced surgeons and high-volume surgeons prescribing higher initial volumes. Several studies that quantified average postoperative narcotic requirements in orthopedic patients have concluded many narcotic pills prescribed at discharge are not used. Kim et al17 examined 1416 patients undergoing outpatient elective upper extremity surgery and found patients were prescribed 24 narcotic pills on average but only consumed 8 pills. They concluded patients were being prescribed 3 times more opioid medications than were necessary. Similarly, Rodgers et al18 reported 250 patients who underwent elective upper-extremity surgery consumed only one-third of their 30 opiate pills postoperatively. In a prospective study of 100 patients who underwent outpatient shoulder surgery, Kumar et al19 found the median number of pills prescribed for all procedures was 60 pills, with a median of 13 pills remaining on postoperative day 90.

This trend continued for elective foot and ankle procedures. Merrill et al20 investigated postoperative pain management with multimodal analgesia in 171 patients undergoing bony and soft tissue foot and ankle procedures. They concluded half the number of short-acting narcotics could have been prescribed to adequately treat patients' pain. Sabatino et al21 examined prescribing data after 5 common orthopedic surgical procedures. They reviewed data from 1199 surgeries and found that after 61% of these procedures, patients reported remaining opiate pills, introducing more than 43,000 unused opiate pills into circulation. Efforts to standardize the number of narcotic pills needed after elective orthopedic procedures may reduce the pill burden in the community.

The current survey revealed significant efforts to prescribe multimodal pain protocols, NSAIDs, and Tylenol to reduce opiate consumption postoperatively. However, most respondents did not have department-wide guidelines on pain medication prescribing postdischarge.

Multimodal pain protocols and preoperative patient education have been used in other studies to reduce postoperative opiate consumption. Alter and Ilyas22 conducted a prospective randomized comparison of consecutive carpal tunnel release surgeries. Patients were randomized to receive either preoperative opiate counseling or no intervention. Patients who underwent preoperative counseling consumed significantly less opioid pills (1.4 vs 4.2), with no significant difference in postoperative pain scores. Gangavalli et al23 identified unemployment, lower income, and history of substance abuse as risk factors for misuse of opioids in the orthopedic trauma population.

Stanek et al24 reported a division-wide multimodal protocol for postoperative pain management significantly decreased opioid prescription size and limited prescribing variability. Attum et al25 reviewed the charts of 88 orthopedic trauma patients who underwent fixation of a femoral shaft fracture from 2013 to 2015. They also found significant variability with prescribing patterns and a lack of standardization, despite the same procedure being performed.

These studies illustrate an opportunity exists to reduce the opiate burden in the community and to establish guidelines to standardize pain management protocols at a departmental level. The current study did not find an association with THA or TKA performed in an ASC and the number of opiate pills prescribed, suggesting that this setting does not appear to be substantially contributing to opiate prescriptions.

Recently, the US Senate Health Committee voted to approve the Opioid Crisis Response Act of 2018, which will seek to spur development of nonopiate painkillers; increase grant funding for state-specific prevention, response, and treatment for substance abuse; and encourage more responsible and limited prescribing of opioid painkillers. The act also will promote education and training for prescribers of narcotic pain medications, which undoubtedly will include orthopedic surgeons and advanced practice providers. As a community, it is important to take action to mitigate the opioid crisis and forge universal evidence-based prescribing protocols.

The current study has several limitations. Because only 12% of AAHKS members completed the survey, a response bias may exist in the respondent group, and overall practice patterns may differ in reality from what was reported. In addition, this survey presented several doses of medications and surveyed overall number of pills prescribed instead of using morphine equivalent dosing (MED). Conversion to MED could help better compare and contrast the potency of narcotic medications that are being prescribed. Despite these limitations, this is the largest survey regarding opiate- and nonopiate-prescribing habits among THA and TKA surgeons in the United States.

Conclusion

Despite performing a relatively standardized procedure, significant variability exists with regard to postdischarge opiate and nonopiate analgesia-prescribing patterns after primary THA and TKA. Optimizing both current pain management protocols and prescribing habits through the establishment of evidence-based practice guidelines may help orthopedists provide a unified, evidence-based, and safe regimen in the postoperative period for patients to ease pain and decrease the opiate burden in the surrounding community.

References

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  20. Merrill HM, Dean DM, Mottla JL, Neufeld SK, Cuttica DJ, Buchanan MM. Opioid consumption following foot and ankle surgery. Foot Ankle Int. 2018;39(6):649–656. doi:10.1177/1071100718757527 [CrossRef]
  21. Sabatino MJ, Kunkel ST, Ramkumar DB, Keeney BJ, Jevsevar DS. Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures. J Bone Joint Surg Am. 2018;100(3):180–188. doi:10.2106/JBJS.17.00672 [CrossRef]
  22. Alter TH, Ilyas AM. A prospective randomized study analyzing preoperative opioid counseling in pain management after carpal tunnel release surgery. J Hand Surg Am. 2017;42(10):810–815. doi:10.1016/j.jhsa.2017.07.003 [CrossRef]
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Survey Questions on Prescribing Habits of Opiate and Nonopiate Pain Medications

In what state or US territory do you currently work?
How many years have you been in practice?
Approximately how many total hip and knee replacements do you perform each year?
Do you have departmental or service-level guidelines on postoperative opiate prescribing?
Do you perform total hip or total knee replacement from an ambulatory surgery center?
What narcotic medications do you prescribe for patients at discharge after total hip replacement?
How many total narcotic pills are prescribed at discharge after total hip replacement?
What other medications are prescribed at discharge for pain after total hip replacement?
How many total narcotic pills are prescribed at discharge after total knee replacement?
What narcotic medications do you prescribe for patients at discharge after total knee replacement?
What other medications are prescribed at discharge for pain after total knee replacement?

Respondent Demographics

CharacteristicNo. (%)
Years in practice
  0–516 (4.92)
  6–1050 (15.38)
  11–1549 (15.08)
  16–2045 (13.85)
  21–2562 (19.08)
  26–3061 (18.77)
  31+42 (12.92)
  Total325
Annual no. of total joint replacements
  0–10016 (4.94)
  101–20053 (16.36)
  201–30081 (25.00)
  301–40064 (19.75)
  401–50047 (14.51)
  501–60033 (10.18)
  601+30 (9.26)
  Total324
Use of ambulatory surgery center
  Yes, most5 (1.54)
  Yes, but less than half67 (20.61)
  No253 (77.85)
  Total325
Departmental prescribing guidelines
  Yes98 (30.15)
  No227 (69.85)
  Total325

Opioid- and Nonopioid-Prescribing Habits of Pain Medication After Primary THA

ParameterNo. (%)
Narcotics prescribed after THA
  0–4071 (22.76)
  41–80165 (52.88)
  >8076 (24.36)
Pain medication at discharge
  NSAID180 (57.69)
  Tylenol147 (41.72)
  Multimodal63 (20.19)
  Other39 (12.50)
Type of narcotic prescribed at discharge
  Short-acting308 (98.72)
  Long-acting46 (14.74)

Opioid- and Nonopioid-Prescribing Habits of Pain Medication After Primary TKA

ParameterNo. (%)
Narcotics prescribed after TKA
  0–4057 (18.33)
  41–80157 (50.48)
  >8097 (31.19)
Pain medication at discharge
  NSAID224 (72.03)
  Tylenol136 (43.37)
  Multimodal68 (21.86)
  Other35 (11.25)
Type of narcotic prescribed at discharge
  Short-acting307 (98.71)
  Long-acting54 (17.36)

Association Between Opiates Prescribed and Selected Surgeon Demographics After THA

DemographicNo. (%)P

60 Opiate Pills>60 Opiate PillsTotal
Respondents180 (57.7)132 (42.3)312
Years in practice as a surgeon.05
  0–55 (2.8)10 (7.6)15 (4.8)
  6–1020 (11.1)28 (21.2)48 (15.4)
  11–1529 (16.1)19 (14.4)48 (15.4)
  16–2029 (16.1)16 (12.1)45 (14.4)
  21–2533 (18.3)26 (19.7)59 (18.9)
  26–3039 (21.7)21 (15.9)60 (19.2)
  >3025 (13.9)12 (9.1)37 (11.9)
Annual volume of primary THA.13
  0–1008 (4.5)5 (3.8)13 (4.2)
  101–20038 (21.2)15 (11.4)53 (17.0)
  201–30047 (26.2)31 (23.5)78 (25.0)
  301–40034 (19.0)29 (22.0)63 (20.2)
  401–50020 (11.2)25 (18.9)45 (14.4)
  501–60018 (10.1)11 (8.3)29 (9.3)
  >60015 (7.8)16 (12.1)31 (9.9)

Association Between Opiates Prescribed and Selected Surgeon Demographics After TKA

DemographicNo. (%)P

60 Opiate Pills>60 Opiate PillsTotal
Respondents165 (53.1)146 (46.9)311
Years in practice as a surgeon.06
  0–53 (1.8)12 (8.2)15 (4.8)
  6–1021 (12.7)28 (19.1)49 (15.8)
  11–1527 (16.4)19 (13.0)46 (14.8)
  16–2024 (14.6)20 (13.7)44 (14.1)
  21–2530 (18.2)29 (19.9)59 (19.0)
  26–3037 (22.4)23 (15.8)60 (19.3)
  >3023 (13.9)15 (10.3)38 (12.2)
Annual volume of primary TKA<.01
  0–1009 (5.5)6 (4.1)15 (4.8)
  101–20038 (22.6)16 (11.0)54 (17.4)
  201–30047 (28.7)29 (19.9)76 (24.4)
  301–40031 (18.9)31 (21.2)62 (19.9)
  401–50014 (8.5)31 (21.2)45 (14.5)
  501–60014 (8.5)15 (10.3)29 (9.4)
  >60012 (7.3)18 (12.3)30 (9.7)

Multivariate Estimates of the Association Between the Number of Narcotic Pills Prescribed and Surgeon and Practice Demographics

DemographicPrimary THAPrimary TKA


Odds Ratio95% CIPOdds Ratio95% CIP
Years of experience
  ≤10ReferenceReference
  11 to 200.33a0.15–0.70<.010.35a0.16–0.75.01
  >200.34a0.17–0.68<.010.30a0.18–0.76.01
Annual surgical volume
  ≤200ReferenceReference
  201 to 4001.660.81–3.39.161.580.79–3.19.20
  >4002.36b1.08–5.13.033.73a1.74–7.98<.01
Departmental guidelines
  YesReferenceReference
  No0.951.08–5.13.860.840.47–1.52.56
Ambulatory surgery center
  Yes, most casesReferenceReference
  Yes, less than half of cases0.160.01–1.91.150.240.02–3.20.28
  No0.190.02–2.14.180.260.02–3.24.30
Use of multimodal pain medication
  NoReferenceReference
  Yes0.830.38–1.80.630.710.26–1.94.51
Authors

The authors are from the Department of Orthopaedics and Rehabilitation (JSL, CPT, ASG, ZZ, AL, BFR), University of Rochester Medical Center, and the Department of Orthopedic Surgery (CPT, BFR), Center for Musculoskeletal Research, University of Rochester School of Medicine, Rochester, New York.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Benjamin F. Ricciardi, MD, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 1000 South Ave, Ste 050, Rochester, NY 14620 ( Benjamin_Ricciardi@urmc.rochester.edu).

Received: August 31, 2018
Accepted: November 13, 2018
Posted Online: July 29, 2019

10.3928/01477447-20190723-06

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