SLR - April 2022 - Jennifer Levi
Reference: Rowe S, Zagales I, Fanfan D, Gargano T, Meneses E, Awan M, Zagales R, McKenney M, Elkbuli A. Postoperative Opioid Prescribing Practices in Us Adult Trauma Patients: A Systematic Review. J Trauma Acute Care Surg. 2022 Feb 1;92(2):456-463. doi: 10.1097/TA.0000000000003341. PMID: 34238859.Level of Evidence: Level III
Scientific Literature Review
Reviewed By: Jennifer Levi, DPM
Residency Program: Temple University Hospital – Philadelphia, PA
Podiatric Relevance: The opioid epidemic continues to be a nationwide problem requiring diligence and awareness from prescribers in every specialty. Lower extremity trauma, and in turn post-operative analgesia, is something podiatric practitioners commonly encounter in practice. There remains a lack of guidelines regarding proper opioid prescription practices in postoperative trauma patients. This article aims to assist in establishing these guidelines by analyzing current prescribing practices in this patient population.
Methods: This was a systematic review performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed and Cochrane Journals were searched to identify studies published in English from October 2010 to December 29, 2020, evaluating the utilization of opioid prescriptions in surgically managed US adult trauma population. The main outcome was to identify discrepancies of MMEs (morphine milligram equivalents) prescribed within varying cohorts and demographics. The primary outcomes included influence of prior opioid history on prescription practices, opioid prescription based on surgical practices and opioid prescription patterns between age cohorts.
Results: A total of 30,249 patients were analyzed. The literature review suggests that there is a variation in prescription patterns between opioid naïve vs. opioid exposed patients. Four of the 10 cohort studies that included information on prior opioid use within their population investigated both patients with a prior history of opioid use and those naive to opioids. The data also found that opioid prescriptions were higher in orthopedic trauma surgery patients compared to non-orthopedic trauma surgeries. For example, Rodriguez-Buitrago et al. found that opiate-naive patients were prescribed significantly more opioids by orthopedic prescribers (total mean of 2,432 ± 1,669 MMEs) than nonorthopedic prescribers (mean, 864 ± 1,702 MMEs; p < 0.05) for the exact same injury.
Finally, there was no consensus in the literature on the effects of age on prescribing behavior.
Conclusions: The authors recommended regular review of the prescription drug monitoring data in patients with a history of prior opioid prescription use and close surveillance to help address discrepancies in treatment between patients who are opiate naïve and those with a history of prior use. They also recommended a tiered system of opioid prescription with consideration of the type of surgery the patient underwent. One of the articles reviewed showed a decrease in opioid prescription MME after implementing a guideline, reinforcing one of the aims of this study. Lastly, the authors had no meaningful recommendations for age related prescribing patterns given the lack of data on the topic.