Opioid Prescription Patterns in Hand Surgery: A Medicare Part D Analysis

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After a 17-year progressive increase in prescription opioid deaths in the United States, the US Department of Human and Health Services (HHS) declared the opioid crisis to be a public health emergency in 2017. The number of prescription opioid-related deaths decreased from 2017 to 2019 but rose up again by 16% in parallel with the COVID pandemic in 2020. The opioid crisis is complex and stems from many factors, including both increases in prescriptions as well as accessibility to heroin and synthetic drugs. Frank misuse of prescription opioids continues to be a significant factor driving the epidemic, with over 10 million people shown to have misused prescription opioids and 1.6 million people misusing prescription opioids for the first time in 2019.²

The surgical patient in acute pain presents a unique challenge in regard to overall opioid misuse. Research suggests that over 70% of post-procedure opioid prescriptions remain unused, highlighting the importance of prescribing habits.³ General surgeons have been found to contribute over 36% of all opioid prescriptions, with other surgical subspecialties such as otolaryngology, urology, and ophthalmology contributing 4% to 17%.^4-7 Within hand surgery, upwards of 13% of opioid-naive patients continue to fill their prescriptions beyond 90 days of their procedure, despite otherwise needing minimal pain management.⁸ Non-inferiority trials have shown pain outcomes and associated complication rates with the use of over-the-counter medications vs opioids to be similar; however, postoperative complication rates are higher with opioid use.^9,10

Medicare is the national health insurance program in the United States that provides coverage for over 60 million Americans aged 65 years and older as well as younger people with disabilities. Despite evidence showing older adults are at higher risk of harm from opioids, there is a gap in evidence on hand surgery-associated opioid prescription patterns specifically within this Medicare population.¹¹ Other studies have indicated large, practice-level variations in prescription habits, with roughly half of carpal tunnel release (CTR) patients receiving postoperative opioids.¹² However, uncertainty remains regarding the relationship between postoperative opioid use and older adults undergoing a wide variety of procedures delivered by hand surgeons. Currently, there are unclear national or regional recommendations for opioid prescription in the setting of CTR and hand surgeries in general, and providers often follow institution-based practices. As such, this project set out to describe the longitudinal and geographic trends of opioid prescription habits of hand surgeons in the postoperative Medicare population.

Data collection

The Centers for Medicare and Medicaid Services Medicare Part D Prescription Drug Program Prescribers Public Use File (PUF) was used to extract state, local, and individual provider-level prescription data for the years 2015 to 2019. The PUF contains information pertaining to 70% of the drugs prescribed by providers to Medicare beneficiaries paid for by the Medicare Part D Prescription Drug Program. The prescriber type was limited to providers identified as hand surgeons who practiced in the continental United States. Furthermore, prescribers who wrote 10 or fewer opioid prescriptions to Medicare Part D beneficiaries within a given calendar year were excluded from the database.

The variables extracted and used included the National Provider Identifier (NPI), provider gender, state of practice, year, total prescription claim count, total prescription claim cost, opioid claim count, opioid drug cost, and beneficiary count (per state). Total prescription claims include both the initial prescription and refills.

Geographic and provider-level analysis

To evaluate regional and state-level trends, we organized states into regions according to the US Census Bureau’s 2010 Census Regions and Divisions.¹³ Total opioid claim counts were aggregated between 2015 and 2019 within each state, and then within each regional division. Opioid claim counts were also aggregated within the 5-year period of analysis (2015-2019) based on unique NPI. The percentage of opioid claims was calculated as the proportion of opioid claims to the total prescription claims. The gender of each hand surgeon was also extracted from the data and evaluated based on prescribing patterns. In addition, the length of prescription was defined as an aggregate number of days’ supply of opioids. The average number of days per prescription was then stratified by year, prescriber gender, and prescriber region, which allowed for the creation of a density heat map averaged over 5 years. The median prescribing rate was defined as the total number of prescriptions and refills provided per surgeon.

Statistical analysis

Descriptive statistical analysis was conducted to present counts and percentages for categorical variables and means and SDs for continuous variables. Statistical significance was predetermined for any P-value less than .05. Microsoft Excel (Microsoft Corp) was used to organize the PUF. All other analyses were performed using RStudio R version 4.1.1 (R, Foundations for Computational Statistics). This study was exempt by UNC-Chapel Hill Institutional Review Board as it did not constitute human subjects research as defined under federal regulations [45 CFR 46.102 (e or l) and 21 CFR 56.102(c)(e)(l)].

National trends

A total of 1752 hand surgeons were identified in the Medicare Part D database from 2015 to 2019. In this time, the total number of opioid prescriptions among hand surgeons peaked in 2017 and decreased in the subsequent 2 years (Table 1). Though the total number of prescriptions increased from 2015 to 2019, the median prescribing rate (2015: 61.4%; 2016: 60%; 2017: 58%; 2018: 55.5%; 2019: 55.3%), percentage of opioid claims (2015: 55.4%; 2016: 54.8%; 2017: 53.4%; 2018: 51.3%; 2019: 48.27%), and average days per claim (2015: 6.3; 2016: 6.1, 2017: 5.8; 2018: 5.2 2019: 4.67) decreased every year.

Averaged across 5 years, 88.2% and 11.74% of the total hand surgeons were male and female, respectively. Male hand surgeons had higher average opioid prescription claims than female hand surgeons every year between 2015 and 2019. In both 2018 and 2019, male surgeons wrote opioid prescriptions for more days as compared with their female counterparts (P = .02, P = .03; Table 2).

Regional trends

When divided into 4 geographic regions, the Northeast had a lower proportion of total opioid prescriptions as compared with the Midwest and the West (Table 3). The South and Northeast had similar proportions of total opioid prescriptions; however, prescriptions by hand surgeons in the South were significantly longer in duration for every year (6.13 days vs 5.03 days; P < .001). After 2017, the West, Midwest, and Northeast averaged under 5 days per opioid prescription, whereas the South remained above 5 days through 2019 (South: 5.03 days; Northeast: 4.19 days; Midwest: 4.50 days; West: 4.41 days).

In addition to the proportion of opioid prescriptions and length of prescription, the average number of opioid prescriptions per hand surgeon also varied widely by region (Table 4). Nationally, the average number of opioid claims per provider between 2015 and 2019 was 330 (SD 149). Overall, the Northeast had the lowest average of opioid claims per surgeon (218), followed by the West (258), the Midwest (375), and the South (453). Further stratification by the 9 US census regions demonstrated the lowest number of opioid claims per provider in the New England region (191) and the highest average in the East South-Central region (518). A geographic distribution of opioid claims per hand surgeon for all states can be seen in Figure 1. The geographical trend of the proportion of opioid claims to total claims differed, with the highest in the Midwest (58%) and West (57%) and the lowest in the Northeast (49%) and South (50%) (Table 4).

Figure 1. Geographic distribution of opioid prescriptions prescribed per hand surgeon from 2015 to 2019.

The 9 US Census regions were trended longitudinally, and opioid claims were compared to the entire opioid claim burden by hand surgeons in the nation (Figures 2 and 3). While most regions had similar or decreased proportions from 2015 to 2019, the West South-Central region showed an increase in the proportion of opioid claims (Figures 2 and 3).

Figure 2. Five-year proportion of opioid claims to total opioid claim count, by state.

Figure 3. Annual proportion of opioid claims, stratified by US regions.

There has been a tremendous focus on research and policy changes since the HHS declared the opioid crisis to be a public health emergency. Surgeons play a unique role in prescription opioids by balancing the need to control postoperative pain effectively with patient safety. As the first nationwide analysis of opioid prescribing patterns among hand surgeons, this study shows that the median prescribing rate of hand surgeons and the proportion of opioid claims out of total claims decreased each year from 2015 to 2019, with the biggest decrease occurring from 2017 to 2019. However, there were significant regional and state-level variations in prescribing patterns, reflecting the need for more standardized guidelines and opportunities for practice change. To date, there is no definitive consensus delineating appropriate opioid prescription patterns in the Medicare hand surgery population. Most legislation regarding opioid prescribing patterns has been made at an institutional or state level, which has resulted in variability throughout the United States.^14-17

Since Massachusetts first enacted legislation limiting the initial prescription of opioids for acute pain in 2016, 36 states followed suit. Some states have even placed limitations on the volume of pills or even indications for prescription but range on stipulations regarding days, insurance payers, and milligram equivalents. Many legislations were first in Northeastern states, with others passed in late 2017 through 2018. These variations in legislation may explain the trends noted in the current analysis by geographic region.

By the end of 2017, all 50 states joined the Prescription Drug Monitoring Program (PDMP) to allow physicians and pharmacists to track patient history of controlled substances. However, there have been mixed results on the effectiveness of the PDMP to reduce the number of prescriptions and overdoses.¹⁸ For example, despite all states being a part of the PDMP, only 23 states mandate all prescribers and dispensers enroll in the program.¹⁹ Furthermore, only 13 states require both prescribers and dispensers to check the PDMP before writing or filling a prescription, despite evidence suggesting a 10% reduction in opioid prescriptions in states participating fully in the PDMP.²⁰ A large barrier to implementation is that PDMP is an independent program not well integrated with current electronic health record companies such as EPIC and failed to engage both patients and physicians. In contrast, states or institutions that use quality improvement frameworks that are patient-focused and physician-driven have found success in decreasing excessive opioid prescribing across multiple different surgical specialties without compromising patient satisfaction or pain control.^21-24 

One concern regarding the generation of opioid prescription guidelines for postoperative care is the wide variety of procedures and patient factors, necessitating individualized patient-centered care. As such, we believe prescribers must be the primary drivers of such initiatives, specifically within the field of hand surgery. The Michigan Surgical Quality Collaborative successfully developed prescribing guidelines for 32 different surgical procedures to decrease prescription size and opioid use while maintaining quality pain control outcomes.¹² Other states could consider similar statewide hospital quality-improvement collaboratives and develop recommendations specific to their population, if necessary.

For surgical providers to be drivers and active participants in reducing patient opioid use, the problem and potential solutions must be built into educational programs. At this time, less than a third of surgical residency programs mandate opioid prescribing education, despite all programs allowing trainees to prescribe opioids.²⁵ Thus, increasing the amount and quality of opioid prescription education for surgical trainees would likely benefit their future practices and patients alike.^26,27

As a public health emergency, the opioid crisis should be addressed through a public health lens with evidence-based guidelines. From the provider level of opioid prescription awareness, hospital-level prescribing guidelines, state-level quality initiatives, and systems-level integration of the PDMP into the medical EMR, there are many avenues in which public policy and educational paradigms can make a difference. To help prioritize these strategies, future research focused on the causes of excess opioid prescribing and practice variation is needed.

Several limitations of this study exist because of the dataset used, which only includes individuals older than 65 years. Although the elderly population is at higher risk from opioid toxicities, surgeons have been shown to be more cautious in this population.^28,29 Thus, the actual prescribing patterns among all ages may be underrepresented. Another limitation of the dataset is the lack of individual-level information, which does not allow for our analyses to account for potential confounding factors such as specific dosage, preexisting chronic pain conditions, or medical comorbidities that would alter postoperative pain control. This also does not allow for sub-analyses by race to study disparities or for different hand procedures, as hand surgeries may range from acute trauma injuries to elective outpatient procedures. The study was also not able to account for the interregional variability of hand surgeons per capita or volume of surgical cases. Furthermore, we were unable to study specific prescribed-dose equivalents among prescriptions. However, Medicare Part D provides a strong dataset and is the largest single payer of opioid prescription coverage, thus allowing for the description of opioid use within the population of patients 65 years and older. While this dataset does include resident physicians, an additional limitation is that it does not include advanced practice providers.

This nationwide analysis of opioid prescribing patterns among hand surgeons treating Medicare beneficiaries from 2015 to 2019 reveals important trends in addressing the opioid crisis within postoperative pain management. We observed a consistent decrease in opioid prescribing rates, with significant reductions between 2017 and 2019. However, notable regional, state-level, and gender-based variations in prescribing patterns persist, highlighting the need for standardized guidelines. Our findings underscore the complex nature of opioid prescribing in hand surgery and the varied impact of state-level legislation and programs like the PDMP. To address these challenges, we propose developing evidence-based guidelines tailored to specific procedures and patient populations, implementing quality improvement frameworks, enhancing opioid prescription education in surgical residency programs, and improving the integration of prescription monitoring programs with electronic health records. By addressing these areas, we can work toward more consistent and appropriate opioid prescribing practices in hand surgery, balancing effective pain management with patient safety.