Why are we prescribing so much narcotic medication after surgery?

A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines

These authors reviewed patients undergoing outpatient upper-extremity surgical procedures over a consecutive 6-month period with respect to patient demographic characteristics, surgical details, anesthesia type, and opioid prescription and consumption patterns. Their concern was that inadvertent overprescribing can lead to excess availability of opioids in the community for potential diversion.

They identified 1,416 patients with a mean age of 56 years (range, 18 to 93 years). Surgeons prescribed a mean total of 24 pills, and patients reported consuming a mean total of 8.1 pills, resulting in a utilization rate of 34%. 

Patients undergoing soft-tissue procedures reported requiring fewer opioids (5.1 pills for 2.2 days) compared with fracture surgical procedures (13.0 pills for 4.5 days) or joint procedures (14.5 pills for 5.0 days) (p < 0.001). 

Patients who underwent wrist surgical procedures required a mean number of 7.5 pills for 3.1 days and those who underwent hand surgical procedures required a mean number of 7.7 pills for 2.9 days, compared with patients who underwent forearm or elbow surgical procedures (11.1 pills) and those who underwent upper arm or shoulder surgical procedures (22.0 pills) (p < 0.01). 

Procedure type, anatomic location, anesthesia type, age, and type of insurance were also all significantly associated with reported opioid consumption (p < 0.001).

They concluded that patients are being prescribed approximately 3 times greater opioid medications than needed following upper-extremity surgical procedures. 

They recommend that surgeons consider some general guidelines for prescribing opioids postoperatively after outpatient upper extremity  

10 opioids for hand and wrist soft tissue surgical procedures, 

20 opioids for hand and wrist fracture or joint surgical procedures,

15 opioids for elbow and forearm soft-tissue surgical procedures, 

20 opioids for elbow and forearm fracture or joint surgical procedures, and

30 opioids for upper arm and shoulder surgical procedures.

Comment: We agree that there is a tendency to over use and over prescribe narcotics after surgery. This trend can be seen starting in the recovery room, where the patient is often asked to rate their pain on a 1-10 scale and then be administered narcotics even though they are tolerating the pain. Of course postoperative narcotics can lead to respiratory depression, urinary retention, confusion, unsteadiness, and the expectation that recovery from surgery will be 'painless'. This trend continues after discharge. We have found it preferable inform patients before surgery that we'll be prescribing minimal narcotics and only administer more if the patient finds that pain is substantial and interfering with their recovery. 

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Narcotic pain medications and joint replacement surgery JBJS - Oxycontin

A recent study in the Journal of Bone and Joint Surgery compared the results of total knee replacement for patients who chronically used narcotic pain medications with those who did not.

The authors found that chronic users of narcotics had much more difficulty recovering, longer hospital stays, more post-surgical pain, a higher rate of complications, and were more likely to need additional procedures than patients who were not opioid-dependent.

While this study did not directly concern patients having shoulder joint replacement, there is every reason to believe that similar findings might be found with patients having total shoulder arthroplasty.

It is important that surgeons and patients recognize this potential relationship and consider a formal approach to narcotic management over the long haul, detoxification to use of alternative forms of pain management, and considerations of withholding this elective surgery until the pain management program was firmly in place.

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