Opioid Prescribing Practices in Plastic Surgery: A Juxtaposition of Attendings and Trainees
Walter J. Joseph, MD1, Ian Chow, MD1, Nicholas Cuccolo, BS2, Emily H. Beers, MD1.
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2Rutgers University - Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
PURPOSE: The opioid epidemic is an undeniable public health crisis that has left physicians, researchers, and policy-makers pointing fingers and grasping for solutions. Prescribing practices among surgeons has recently been under heavy scrutiny and there is a dearth of data in this arena, specifically pertaining to Plastic Surgery. As such, we sought to examine prescribing practices among Plastic Surgery attendings and residents to determine the need for more thorough education and training in both opioid prescribing and in the management of the patients taking these potentially harmful medications post-operatively.
METHODS: A voluntary survey was distributed to all ACGME-accredited plastic surgery residency programs. Information elicited from the survey included demographic characteristics, opioid prescribing practices, and self-rated ability level pertaining to opioid management and patient interactions. Summary statistics were generated. Cumulative Odds Ordinal Logistic Regression with Proportional Odds was used to determine resident trainee comfort level with managing patients requesting additional opioids relative to attending prescribers. Trends in prescribing practices based off of prescriber position were also analyzed; cumulative Odds Ordinal Logistic Regression with Proportional Odds and Chi-Squared tests were utilized for ordinal and nominal variables, respectively.
RESULTS: We received 78 responses with wide representation from Plastic Surgery residency programs across the country. Among responders, 59% were male and 39.7% female. 29.5% were attendings, while 26.9% were senior residents, 29.5% junior residents, and 14.1% interns. Interns reported prescribing oxycodone significantly more than any other group, while attendings seemed to utilize combination medications (i.e. hydrocodone/acetaminophen) more frequently (p<0.03). Hydrocodone alone was rarely prescribed. Interns prescribe significantly fewer pills relative to attendings (p<0.05). Junior residents were 4.49 times more likely and senior residents 3.65 times more likely than attendings to prescribe additional opioids to avoid phone calls and follow-up visits from patients (p=0.012 and 0.029, respectively). When surveyed on a patient's request for additional opioids, interns were 3.99 times more likely to refer the patients to their PCP (p<0.05), while senior residents were more likely to refer to a pain specialist (p<0.04). Rated ability (1-10) in managing patients requesting additional opioid medications showed that interns and senior residents were significantly less comfortable than attendings (median ratings 4 and 5, respectively; p < 0.02). Junior residents had a median rating of 5, which trended toward significance versus attending median rating of 7 (p=0.05). No significant differences were noted in the use of drug screens or Prescription Monitoring Databases.
CONCLUSION: Surgeons are responsible for 9.8% of the total opioid prescriptions in the United States. It is undeniable that Plastic Surgeons play a role in the propagation of the opioid epidemic and it is our moral obligation to implement strategies to curb our contribution. By examining the prescribing practices of residents starting as early as intern year, we have shown that knowledge deficits do exist among trainees and that trainees are significantly less comfortable than their attending counterparts with opioid prescribing and patient management. Therefore, the implementation of more thorough post-operative pain management education in residency may be a cogent strategy in mitigating the opioid crisis.
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