Doctor shopping for narcotics common after trauma surgery

By Fran Lowry

NEW YORK (Reuters Health) - One in five orthopedic trauma patients goes "doctor shopping" for more narcotics after surgery, according to research presented last week.

"Pain control after surgery is very important, but it's also important that you get narcotics from your treating physician and not other doctors in the immediate postoperative period," Dr. Brent Morris, who worked on the study while at Vanderbilt University in Nashville, Tennessee, told Reuters Health. He is now at Texas Orthopedic Hospital in Houston.

"I felt compelled to see how many of our orthopedic trauma patients were trying to get narcotics from other sources because Tennessee, parts of Kentucky, and the Appalachian region in general struggle with the issue of illicit narcotic use, and I wanted to see what role we as surgeons might be playing with regard to the problem," he said.

Dr. Morris and his team presented their research March 11 at the American Academy of Orthopaedic Surgeons (AAOS) annual meeting in New Orleans, Louisiana.

They prospectively studied 151 adult patients who were admitted to their inpatient orthopaedic trauma service in 2011.

The patients had one orthopedic injury such as a broken femur, tibia, or ankle, that required surgery during the same admission.

After discharge, patients got standard care and were prescribed appropriate amounts of narcotics by their treating physicians.

The researchers used the Controlled Substance Monitoring Database (CSMD) for the state of Tennessee to identify all narcotic prescriptions that were filled for the patients 3 months prior to their hospital admission and 6 months following discharge.

"About 49 states have a similar database in place but only eight or nine mandate that physicians use it. Tennessee physicians must use it since the Tennessee Prescriptions Safety Act was passed in 2012. Mandated or not, it's important that we use these databases if we have them," Dr. Morris said.

The researchers found that the prevalence of postoperative doctor shopping for narcotics was 20.8%, despite the fact that the patients were also getting narcotics from their surgeons.

Such doctor shopping was associated with a statistically significant increase in postoperative narcotic prescriptions (two prescriptions vs. seven prescriptions; p<0.001), longer duration of postoperative narcotic use (28 days vs. 112 days; p<0.001), and increased medication per day (26 mg vs. 43 mg; p=0.002).

The researchers also found that patients with a high school education or less were 3.2 times more likely to seek out multiple providers, and patients with a history of narcotic use before their surgery were 4.5 times more likely to doctor shop than were patients with a higher level of education and those who did not report using narcotics before their surgery.

"Those findings really were no surprise, especially that patients who were already taking narcotics continued to take a lot more afterwards, but we don't know why. These are things we could pick up in the emergency room, we can ask, 'Are you currently taking any narcotic medications?' And if they say yes, we could counsel them and say that, 'It may take more narcotics to control your pain afterwards, but I'm your treating surgeon and I should be the one to be prescribing those to you. Please don't obtain narcotics from any other providers in the immediate postoperative period,'" Dr. Morris said.

Dr. Douglas Lundy of Resurgens Orthopaedics in Atlanta, Georgia, told Reuters Health, "The authors of this study are excellent orthopedic surgeons who are trying to shine more of a light on the problem that we know is there."

There are some significant findings in the study, he said.

"One is the significantly longer duration of narcotics that patients who are shopping around are on, rather than the ones who stay with the one doctor. That is interesting because Tennessee and Georgia have these networks where you can actually go online and see how much narcotics patients are taking, so you can get right to the truth," he said.

The other finding, that doctor shoppers already used narcotics before their trauma, "is not surprising to trauma surgeons like myself, because if you are already taking narcotics, many times that will impair your judgment and that will put you at higher risk for injury. Narcotics will not work as well for those people because they develop tolerance over time," he said.

Doctor shoppers seem to be well versed in how to shop around for narcotics, Dr. Lundy added. "The average patient doesn't know that they can do that, whereas people who have prior narcotic use may know they can go around and get these medications from a number of different sources."

Prescribing physicians should use the state databases, Dr. Lundy agreed, but workflow is often an issue, he said.

"In Georgia, it's not a fast log in to get on the database, it takes quite a bit of time. Also, in Georgia, only the doctor can do it so you can't tell your nurse to check a patient on the register, you have to sit on the computer and wait to get the information. So it can be time consuming," he said. "That being said, we have our patients sign a form at the start of treatment that says if they are getting narcotics from somebody else we won't give them any more. Period. It's not negotiable. You're done. We will still care for them. We just won't prescribe them narcotics."

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