Orthopedic surgery trainees are rarely trained in opioid prescribing

By Carolyn Crist

(Reuters News) - Although most orthopedic surgery training programs allow their residents to prescribe opioids, most programs don't provide formal education around it, a new survey suggests.

Furthermore, several of the orthopedic residency program directors who responded to the survey were unaware of local controlled substance regulations, researchers wrote in the American Journal of Surgery.

"When doctors obtain their state licenses, they often have to take a class if they want to be able prescribe controlled substances, but the trainees aren't yet fully licensed," said lead study author Dr. Brian Yorkgitis of the University of Florida College of Medicine-Jacksonville.

More than 49,000 overdose deaths involved opioids in 2017, according to the National Institute on Drug Abuse, and about 19,000 of those were attributed to prescription opioid pain relievers. Orthopedic surgeons account for about 8 percent of the total opioid prescriptions dispensed, according to the American Academy of Orthopaedic Surgeons.

Although the number of opioid prescriptions has been declining, professional education efforts often target licensed prescribers rather than doctors-in-training.

"When we provide education, it's important to reach medical professionals early in their career," Yorkgitis told Reuters Health by phone. "That way we can change a behavior before it becomes a habit."

Yorkgitis and colleagues sent a survey to 163 orthopedic residency programs across the country to understand what controlled substance policies and education programs were in place, as well as the program directors' knowledge about local controlled substance regulations.

Among the 60 completed surveys, 54 programs allowed residents to prescribe opioids to outpatients after surgery. Nine programs required residents to obtain individual registration under the Drug Enforcement Agency, 38 used the hospital's DEA registration, and seven were unsure about DEA registration.

About 45 percent of programs had a mandatory opioid prescribing education program. Six program directors were unsure about a mandatory program, and 16 programs that didn't have an education program were thinking about adding one.

Most of the existing programs were given by lecture, and some were computer-based programs developed at the hospital. The programs were typically one to three hours long.

"We wouldn't let residents perform a procedure if they weren't well-versed and trained in it," Yorkgitis said. "That should apply to other skills such as communication, documentation and prescriptions as well."

About 87 percent of program directors correctly answered questions about their state's laws for prescription drug monitoring programs for fully licensed doctors, and 72 percent correctly answered questions about their state's requirements for mandatory opioid education for fully licensed doctors.

On a five-point scale, the program directors rated the value of opioid prescribing education to clinical care at 4.3 and to resident training at 4.5.

"Although program directors tend to see the value in this education, it doesn't always match up with the willingness or ability to implement a program for residents," said Dr. Michael Gaspar of the Philadelphia Hand to Shoulder Center in Pennsylvania. Gaspar, who wasn't involved with this study, has researched postoperative opioid-prescribing practices.

"Residents are often on the front lines when it comes to prescribing," he told Reuters Health by phone. "These programs didn't exist a decade ago when I was in training, but now that's improving."

Future studies should investigate what's included in these mandatory opioid prescribing education programs, including guidance around when and how much should be prescribed, the study authors wrote.

"There are a lot of studies on opioids and prescriptions out there right now, and we're trying to develop guidelines around what needs to be taken after surgery and how to better educate patients about post-operative pain control," said Dr. Jeff Stepan, an orthopedic surgery resident at the Hospital for Special Surgery in New York City. Stepan, who wasn't involved with this study, has researched alternative methods to control pain and ways for institutions to reduce opioid use.

"We need to have better upfront conversations with patients about surgery and expectations regarding recovery and pain," he told Reuters Health by phone. "We need to do a better job of educating patients that undergoing surgery is painful, and no medicine will take away all the pain."

SOURCE: http://bit.ly/2HEI6jt American Journal of Surgery, online May 6, 2019.