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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe marked, steady increase in the use of prescribed opioids since 2000 is matched by a steady increase in death by drug overdose. In 2008, death by drug overdose surpassed motor vehicle accidents as the leading cause of accidental death in the United States [Warner M et al. National Center for Health Statistics Data Brief #81. 2011]. This article discusses changes in prescription policy, as well as insights into current prescribing patterns, problematic opioid use, and education needs.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedic Pain Management\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedic Pain Management\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedics\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe marked, steady increase in the use of prescribed opioids since 2000 is matched by a steady increase in death by drug overdose (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). In 2008, death by drug overdose surpassed motor vehicle accidents as the leading cause of accidental death in the United States [Warner M et al. National Center for Health Statistics Data Brief #81.2011]. Andrew W. Gurman, MD, Altoona Hand and Wrist Surgery, Altoona, Pennsylvania, USA, stated this is not a street drug problem, with most of the available opioids prescribed by physicians.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/2\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Rates of Drug Overdose Deaths by Major Types of Drugs, USA, 1999\u0026#x2013;2010\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-335287322\u0022 data-figure-caption=\u0022Rates of Drug Overdose Deaths by Major Types of Drugs, USA, 1999\u0026#x2013;2010\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/2\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/2\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/2\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15669\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-3\u0022 class=\u0022first-child\u0022\u003ERates of Drug Overdose Deaths by Major Types of Drugs, USA, 1999\u20132010\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ESource: CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-4\u0022\u003EHydrocodone is the most widely prescribed (131.2 million) medication in the United States [IMS Institute for Healthcare Informatics. \u003Cem\u003EThe Use of Medicines in the United States: Review of 2010.\u003C\/em\u003E 2011]. However, 7 million people are opioid addicts and there are 12 million nonmedical users. Dr. Gurman stressed there is a 66% likelihood a patient will still be taking hydrocodone if they take it every day for 90 days, regardless of the reason for taking it [Martin BC et al. \u003Cem\u003EJ. Gen Intern Med\u003C\/em\u003E 2011 ONDCP. \u003Ca href=\u0022http:\/\/whitehousedrugpolicy.gov\/publications\/pdf\/rx_abuse_plan.pdf\u0022\u003Ehttp:\/\/whitehousedrugpolicy.gov\/publications\/pdf\/rx_abuse_plan.pdf\u003C\/a\u003E].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EOpioid diversion is the major source of nonmedically used prescription drugs. Nearly 56% are obtained from friends or relatives, 9% are purchased from friends or relatives, and 5.4% are taken from friends or family without their knowledge [Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD 2009].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EOne factor contributing to increased prescriptions of opioid analgesics is quality improvement efforts related to pain management. The Joint Commission requires a plan to assess pain, and there has been some movement by others to include pain measurement as the fifth vital sign. Also, reimbursement from the Centers for Medicare and Medicaid Services will be tied to patient satisfaction, which includes pain management. Further, said Dr. Gurman, time pressures for office visits and lack of reimbursement for treatment and evaluation of addiction are contributors, as well as physicians caring about suffering and having long-term relationships with their patients.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EINSIGHTS FROM THE AAOS SURVEY OF FELLOWS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EA survey conducted by the American Academy of Orthopaedic Surgeons (AAOS) provided insights into current prescribing patterns, problematic opioid use, and education needs. A total of 363 (12%) of 3000 AAOS Fellows responded to the Internet-based survey, 25% of whom were general surgeons, primarily performing surgery for hip fractures, long bone fractures, knee arthroplasty, anterior cruciate ligament, carpal tunnel, and trigger finger release, said David C. Ring, MD, Massachusetts General Hospital, Boston, Massachusetts, USA.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe stronger opioids, oxycodone and hydrocodone, were prescribed most frequently (range, 33%\u201363%) at discharge by these surgeons. Dr. Ring noted this was true even for carpal tunnel and trigger finger release surgery. The postoperative duration of opioid prescription ranged from 1 to 7 weeks. An established policy for opioid prescription use for the physician practice was reported by 68%. Dr. Ring noted this is the most effective way to control opioid prescriptions. Seventy-four percent said they would not refill an opioid prescription written by a partner. In 1% to 25% of cases, 86.2% said they would seek help from a pain specialist.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EA prevalence of problematic opioid use in \u22655% of their practice patients was reported by 75% of surgeons. And 48% said that prescribing patterns of orthopedic surgeons contribute to misuse. Further, 58.7% said that tighter regulatory control for ease of access and prescription renewal is needed, while 33% were neutral and 8% said no.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe most important influence on their practice of opioid prescription was what they felt was effective (4.55 on a scale of 0 to 5) and what they were taught (2.51). Although 80% of surgeons said they could tell which patients would be a problem and they had the required communication skills to discuss appropriate opioid use with their patients, 29% said they needed help with communication strategies and setting limits. Guidelines for appropriate opioid prescribing for acute pain were requested by 72.5% of surgeons; for chronic pain by 55.6%; educational materials for limit setting and communication strategy by 80.4%; and for nonopioid pain management by 70%.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESINGLE-CENTER STUDY LED TO CHANGES IN PRESCRIPTION POLICY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EA study by an orthopedic practice with five surgeons showed that 77% of the pills prescribed for pain after outpatient upper extremity surgery were not used, based on patient self-reporting [Rodgers J et al. \u003Cem\u003EJ Hand Surg Am\u003C\/em\u003E 2012]. Jeffrey Rodgers, MD, Des Moines Orthopaedic Surgeons, Des Moines, Iowa, USA, said their findings led to changes in prescribing patterns by their practice that have been effective.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EA total of 250 patients were interviewed by phone between 7 and 14 days after surgery to confirm the medication and regimen prescribed and determine satisfaction with pain control, number of tablets remaining, and whether other analgesic medications were taken. The average of the patients was 54 years and 66.8% were women. Soft tissue surgery was performed in 76.7% and hard tissue in 23.3%.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EAll of the surgeons prescribed 30 pills, which Dr. Rodgers stated tends to be usual practice by all physicians, although there is no evidence to support this number or information regarding the tradition of this norm. Hydrocodone was prescribed for 51% of the patients, oxycodone for 24%, and propoxyphene for 23%. The pain score was reported to be between 0 and 2 by \u223c68% of patients. The patients who had hard tissue surgery used more opioids compared with soft tissue surgery (14 vs 9 pills, respectively).\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EAbout 43% of patients did not use any over-the-counter analgesics, \u223c32% used nonsteroidal anti-inflammatory drugs, and \u223c13% used acetaminophen. Most (52%) patients used their prescribed medication on Days 0 to 2. The mean number of opioid pills used was 10, leaving \u0026gt;4600 pills unused (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). Medicaid patients used more opioids (25 pills) and Medicare patients used significantly less (7 pills; p\u0026lt;0.05) compared with private insurance and workers compensation patients.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/2\/6\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Pill Usage Following Outpatient Surgery\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-335287322\u0022 data-figure-caption=\u0022Pill Usage Following Outpatient Surgery\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/2\/6\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/2\/6\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/2\/6\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15670\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003EPill Usage Following Outpatient Surgery\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Rodgers J et al. Opioid Consumption Following Outpatient Upper Extremity Surgery. \u003Cem\u003EJ Hand Surgery\u003C\/em\u003E 2012. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-16\u0022\u003ELimitations of the study are underreporting by patients, unaccounted procedural complications or postoperative infection, and type of anesthesia.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThe policy of this orthopedic practice now is to prescribe 15 pills of a Schedule III opioid analgesic with one refill. They estimated that 23% of patients would require a refill. More importantly, said Dr. Rodgers, this would lead to a 79% reduction in leftover medication that could be diverted to persons for whom it was not prescribed, which is a leading source of opioids. He also said a prescription with more pills for hard tissue procedures and fewer pills for Medicare patients may be considered.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/2\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzpc6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzpc6p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}