Notable Variability in Opioid-Prescribing Practices After Common Orthopaedic Procedures

Sophia A. Traven, MD; Daniel L. Brinton, PhD; Shane K. Woolf, MD; Lee R. Leddy, MD; Michael B. Gottschalk, MD; Harris S. Slone, MD


J Am Acad Orthop Surg. 2021;29(5):219-226. 

In This Article

Abstract and Introduction


Introduction: The purpose of this study was to evaluate nationwide trends and regional variability in opioid prescriptions after common orthopaedic procedures.

Methods: A retrospective analysis of privately insured subjects from the MarketScan database between 2015 and 2016 was conducted. Median oral morphine equivalents and interquartile ranges were analyzed by region for the initial post-op prescriptions and 90-day total prescriptions for opioid-naive patients undergoing the following: carpal tunnel release; anterior cruciate ligament reconstruction; arthroscopic meniscectomy; bimalleolar ankle fracture open reduction and internal fixation; distal radius fracture open reduction and internal fixation; arthroscopic rotator cuff repair; single-level anterior cervical discectomy and fusion; and total shoulder, hip, and knee arthroplasties. We hypothesized that notable regional variability exists with postoperative narcotic prescribing habits.

Results: Seventy three thousand nine hundred twenty-one opioid-naive patients were identified. A notable regional variability was observed across the United States in the prescriptions given for all procedures, except total joint arthroplasty. Furthermore, although patients undergoing soft-tissue–only procedures required the fewest refills, patients undergoing total joint arthroplasty required the most.

Discussion: Notable regional variability exisits in opioid prescribing patterns for many common orthopaedic procedures. Furthermore, prescriptions were smallest in the region most affected by the opioid epidemic. This information can be used to re-evaluate recommendations, serve as a benchmark for surgeons, and develop institutional and quality improvement guidelines to reduce excess postoperative opioid prescriptions.

Level of Evidence: Level III observational cohort study


No doubt exists that the United States is experiencing an expanding opioid epidemic. Americans consume 80% of the world's global opioid supply while representing only 5% of the world's cohort.[1] The number of drug-related deaths secondary to the prescription of opioids and heroin continues to rise at a concerning rate.[2]

Surgeons are one of the highest prescribers of opioid medications second only to chronic pain specialists.[3–5] Recent estimates suggest, however, that up to 80% of prescribed opioids are not used after surgery.[3–5] Despite this, an alarming 1 in 16 patients becomes a chronic opioid user after a surgical procedure.[3,6] In response to the growing concerns, specialty groups have begun to develop prescription guidelines, legislation regulating the number of opioid pills that can be prescribed at any given time has been passed, and the Center for Medicare and Medicaid Services has proposed quality measures that evaluate surgeons based on their opioid prescribing practices[3,7,8] The Centers for Disease Control and Prevention (CDC) has also weighed in on this issue, urging precaution with prescribing ≥50 oral morphine equivalents (OME) per day and to either avoid or carefully justify increasing the dose to ≥90 OME/d (

Surgeons learn much of their prescribing habits while in residency. Unfortunately, many of these prescribing habits are driven more so by tradition and dogma, rather than by data, which is then perpetuated from generation to generation of surgical trainees. The tendency to overprescribe is further magnified by tying the perception of patient satisfaction scores to be dependent on pain control, the inconvenience of having the patient return to the hospital or clinic for a handwritten opioid prescription should they run out, and the mistaken but previously accepted notion that opioids are rarely addictive.

Compounded, all of these factors result in notable variations in opioid prescribing practices. Although these variations have been shown within single institutional practices, the purpose of this study was to describe regional and national variations in opioid prescribing practices for opioid-naive patients after 10 common orthopaedic procedures including carpal tunnel release; anterior cruciate ligament (ACL) reconstruction; arthroscopic meniscectomy; bimalleolar ankle fracture open reduction and internal fixation (ORIF); distal radius fracture ORIF; arthroscopic rotator cuff repair (RCR); single-level anterior cervical discectomy and fusion (ACDF); and total shoulder, hip, and knee arthroplasties.[8] Our hypothesis is that notable inter- and intra-regional variabilities in opioid prescribing practices exist regarding postoperative narcotic prescribing habits for each of the procedures.