Background: Orthopaedic surgeons are among the highest prescribing physicians of narcotics to opioidnaïve patients. Despite the current opioid epidemic, few studies have specifically quantified the appropriate amount of opioids necessary for postoperative pain control. We hypothesized a significant variability in the quantity of postoperative opioids prescribed among trainee (ie, residents and fellows) and attending surgeons at a single institution.
Methods: Postoperative narcotic prescribing habits were assessed using an anonymous survey. Ultimately, 28 trainee physicians and 17 attending physicians responded to the survey (86.5%). The survey recorded the amount of 5-mg oxycodone tablets that were commonly prescribed to manage pain after various typical orthopaedic procedures (eg, total knee arthroplasty). Non-narcotic analgesic use was also measured. Mean, standard deviation, and variance values were calculated, with significance set at α = 0.05.
Results: After the following procedures, the respondents reported prescribing the following quantities of 5-mg oxycodone tablets: total knee arthroplasty, 56 (SD, 16); total hip arthroplasty, 53 (SD, 13); anterior cruciate ligament reconstruction, 38 (SD, 16); partial meniscectomy, 23 (SD, 14); arthroscopic rotator cuff repair, 39 (SD, 16); carpal tunnel release, 10 (SD, 10); A1 pulley release for treating trigger finger, 9 (SD, 9); open reduction and internal fixation (ORIF) for treating distal radius fractures, 32 (SD, 16); and ORIF for treating ankle fractures, 39 (SD, 15). Statistically significant variation existed between trainee and attending physicians for total hip arthroplasty and A1 pulley release. There was no difference for acetaminophen or nonsteroidal anti-inflammatory drugs, with about 70% of patients receiving at least one of these adjuncts.
Conclusions: Variability exists in postoperative opioid prescribing habits between trainee and attending physicians at the academic training institution we accessed. In light of the ongoing opioid epidemic, institutions may benefit from standardized postoperative pain protocols

Mulawka, Brett S

Price, Ryan C

Richter, Dustin L

Shultz, Christopher L

Treme, Gehron P

English

University of New Mexico

88 EDUCATION ARTICLES • UNMORJ VOL. 8 • 2019
Comparison of Narcotic Prescribing Habits 
Between Trainee and Attending Orthopaedic 
Surgeons
Christopher L. Shultz, MD*; Ryan C. Price, MS†; Brett S. Mulawka, MD*a;  
Dustin L. Richter, MD*; Gehron P. Treme, MD*
*Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, 
Albuquerque, New Mexico
†School of Medicine, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
Changed Affiliation
aB. S. Mulawka, MD. Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts
Corresponding Author Christopher L. Shultz, MD. Department of Orthopaedics & Rehabilitation, MSC10 5600,  
1 University of New Mexico, Albuquerque, NM 87131 (email: cshultz2@salud.unm.edu). 
Funding The authors received no financial support for the research, authorship, and publication of this article.
Conflict of Interest The authors report no conflicts of interest.
ABSTRACT
Background: Orthopaedic surgeons are among the 
highest prescribing physicians of narcotics to opioid-
naïve patients. Despite the current opioid epidemic, 
few studies have specifically quantified the appropriate 
amount of opioids necessary for postoperative pain 
control. We hypothesized a significant variability 
in the quantity of postoperative opioids prescribed 
among trainee (ie, residents and fellows) and attending 
surgeons at a single institution. 
Methods: Postoperative narcotic prescribing habits 
were assessed using an anonymous survey. Ultimately, 
28 trainee physicians and 17 attending physicians 
responded to the survey (86.5%). The survey recorded 
the amount of 5-mg oxycodone tablets that were 
commonly prescribed to manage pain after various 
typical orthopaedic procedures (eg, total knee 
arthroplasty). Non-narcotic analgesic use was also 
measured. Mean, standard deviation, and variance 
values were calculated, with significance set at  
α = 0.05. 
Results: After the following procedures, the 
respondents reported prescribing the following 
quantities of 5-mg oxycodone tablets: total knee 
arthroplasty, 56 (SD, 16); total hip arthroplasty, 53 (SD, 
13); anterior cruciate ligament reconstruction, 38 (SD, 
16); partial meniscectomy, 23 (SD, 14); arthroscopic 
rotator cuff repair, 39 (SD, 16); carpal tunnel release, 
10 (SD, 10); A1 pulley release for treating trigger 
finger, 9 (SD, 9); open reduction and internal fixation 
(ORIF) for treating distal radius fractures, 32 (SD, 
16); and ORIF for treating ankle fractures, 39 (SD, 15). 
Statistically significant variation existed between trainee 
and attending physicians for total hip arthroplasty 
and A1 pulley release. There was no difference for 
acetaminophen or nonsteroidal anti-inflammatory drugs, 
with about 70% of patients receiving at least one of 
these adjuncts.
Conclusions: Variability exists in postoperative 
opioid prescribing habits between trainee and 
attending physicians at the academic training 
institution we accessed. In light of the ongoing opioid 
epidemic, institutions may benefit from standardized 
postoperative pain protocols. 
Keywords: Narcotic, Opioid, Postoperative, Pain Control
INTRODUCTION
The opioid epidemic in the United States has reached 
catastrophic proportions, with opioid overdoses now 
the leading cause of death related to unintentional 
injury.1,2 In certain states, deaths due to fentanyl and 
other synthetic opioids have increased by 219% from 
2010 to 2015—an increase driven largely by illicitly 
manufactured fentanyl.3,4 The state of New Mexico ranks 
twelfth in the country in drug overdose deaths, with 
a rate that is 25% higher than the national average.5 
Data from 2017 indicate that prescription drugs were 
involved in 68% of drug overdose deaths in the state.6 
Additionally, the New Mexico Department of Health 
reported that prescription opioids caused the most 
unintentional drug overdoses at 47% between 2011  
and 2015.5
Orthopaedic surgeons play a vital role in the opioid 
epidemic. Nationally, they account for about 7.7% of 
total opioid prescriptions filled and are only surpassed 
by general practitioners, internists, and dentists.7 To 
further complicate the situation, between 21% to 29% 
of patients misuse prescribed opioids for chronic pain, 
with an estimated 4% to 6% of those transitioning to 
heroin.7-10
Despite the opioid epidemic, few studies have quanti-
fied the optimal number of opioids needed for managing 
89EDUCATION ARTICLES • UNMORJ VOL. 8 • 2019
postoperative pain, particularly in relation to specific 
procedures. The resources that do exist typically offer 
broad-based suggestions on multimodal pain manage-
ment.11,12 Owing to the lack of data, we hypothesized that 
there would be a high variability in the quantity of postop-
erative opioids prescribed among trainee physicians (ie, 
residents and fellows) and attending physicians in an 
orthopaedic department at a single institution.
METHODS
We received approval from our Human Research Review 
Committee (HRRC #17-483). Study participants included 
trainee and attending physicians of the orthopaedic 
residency program at a level 1 trauma center, The 
University of New Mexico Hospital. An anonymous 
online survey (SurveyMonkey Inc, San Mateo, CA) was 
distributed and completed by 28 trainee physicians and 
17 attending physicians, with an 86.5% response rate. 
Prescribing habits were evaluated by querying 
the quantity of 5-mg oxycodone tablets routinely 
prescribed postoperatively after common orthopaedic 
procedures. Prescribing habits for non-narcotic 
analgesia, specifically acetaminophen and nonsteroidal 
anti-inflammatory medications (NSAIDs), were also 
queried. The following procedures were included: total 
knee arthroplasty (TKA), total hip arthroplasty (THA), 
anterior cruciate ligament (ACL) reconstruction, partial 
meniscectomy (PM), arthroscopic rotator cuff repair 
(RCR), carpal tunnel release (CTR), A1 pulley release 
for treating trigger finger, open reduction and internal 
fixation (ORIF) for treating distal radius fractures, and 
ORIF for treating ankle fractures. The mean, standard 
deviation, and variance between trainee and attending 
physicians were calculated. The α was set to a 0.05 
significance level. 
RESULTS
The average number of 5-mg oxycodone tablets 
prescribed for each procedure was as follows: TKA, 56 
(SD, 16); THA, 53 (SD, 13); ACL reconstruction, 38 (SD, 16); 
PM, 23 (SD, 14); arthroscopic RCR, 39 (SD, 16); CTR, 10 
(SD, 10); A1 pulley release for treating trigger finger,  
9 (SD, 9); ORIF for treating distal radius fractures, 32 (SD, 
16); and ORIF for treating ankle fractures, 39 (SD, 15). 
There was a statistically significant difference in the 
number of tablets prescribed between trainee and 
attending physicians after THA (P = 0.03) and A1 pulley 
release for treating trigger finger (P = 0.05; Figure 1). 
Notably, there were differences in prescribing that 
approached statistical significance after TKA (P = 0.08) 
and PM (P = 0.06). There was no statistical difference in 
prescribing habits for acetaminophen or NSAIDs, with 
about 70% of patients receiving at least one of these 
adjuncts (Figure 2). There were various responses 
regarding the amounts of 5-mg oxycodone tablets 
prescribed after procedures (Table 1). There were no 
observed prescribing differences among trainee 
physicians by postgraduate year.
Figure 1. Trainee versus attending physicians’ quantity of opioid prescribed after various orthopedics procedures. 
Star (*) denotes statistically significant difference. Error bars represent standard deviation. TKA, total knee 
arthroplasty; THA, total hip arthroplasty; ACL, anterior cruciate ligament; PM, partial meniscectomy; RCR, rotator cuff repair; 
CTR, carpal tunnel release; TF, trigger finger; ORIF DR, open reduction and internal fixation for treating distal radius fractures; 
ORIF ankle, open reduction and internal fixation for treating ankle fractures.
90 EDUCATION ARTICLES • UNMORJ VOL. 8 • 2019
DISCUSSION
In our study at a single institution, we found a high rate 
of variation in the self-reported narcotic prescribing 
habits of the respondents. Specifically, there were 
significant differences between trainee and attending 
physicians for number of prescribed opioids after 
THA and A1 pulley release for treating trigger finger. 
Attending physicians typically prescribed more than did 
trainees. 
Reasons for this difference are likely multifactorial. 
First, THA and A1 pulley release for treating trigger 
finger represent both extremes of expected 
postoperative pain, with A1 pulley release being one of 
the least painful procedures and THA being one of the 
most. Second, both procedures are almost exclusively 
performed by hand and joint surgeons within our 
department. The surgeons who do not perform these 
procedures regularly are less likely to have developed 
routine prescribing habits. Third, attending physicians 
who were trained before recognition of the opioid 
epidemic and who do not routinely perform A1 pulley 
release and THA are more likely to prescribe more 
opioids for these procedures. Both procedures were 
associated with a wide range of 5-mg oxycodone tablet 
Figure 2. Trainee, attending, and combined prescribing patterns for non-narcotic postoperative pain medication. 
NSAIDs, non-steroidal anti-inflammatory drugs. 
Table 1. Survey results showing reported ranges of postoperative oxycodone tablets (5 mg) prescribed after 
common procedures by trainee physicians, attending physicians, and both 
Procedure No. prescribed by 
trainee physicians 
(range)
No. prescribed 
by attending 
physicians (range)
No. prescribed by trainee 
and attending physicians 
combined (range)
TKA
THA
ACL reconstruction
PM
Arthroscopic RCR
CTR
A1 pulley release for treating TF
ORIF for treating DR fractures
ORIF for treating ankle fractures
28-90
28-90
20-60
5-60
20-80
0-40
0-30
10-60
15-60
45-120
45-60
20-90
0-60
20-90
0-30
0-30
15-90
20-90
28-120
28-90
20-90
5-60
20-90
0-40
0-30
10-90
15-90
TKA, total knee arthroplasty; THA, total hip arthroplasty; ACL, anterior cruciate ligament; PM, partial meniscectomy; RCR, rotator cuff repair; CTR, 
carpal tunnel release; TF, trigger finger; ORIF, open reduction and internal fixation; DR, distal radius.
91EDUCATION ARTICLES • UNMORJ VOL. 8 • 2019
quantities that the respondents reported prescribing 
for a given procedure. 
In the current study, each procedure was associated 
with a surprisingly wide range of 5-mg oxycodone 
tablets prescribed to the patients. Regarding trainee 
physicians, the prescribed quantity for arthroscopic 
RCR ranged from 20 to 80 of the 5-mg oxycodone 
tablets. This difference is even more apparent when 
including both trainee and attending physicians, 
ranging from 28 to 120 of the 5-mg oxycodone tablets 
after TKA (Figure 1). 
Large variations in narcotic prescribing habits 
have been well documented in emergency medicine 
and obstetric studies. In a single institution review 
of narcotic prescriptions for women discharged 
postpartum, Badreldin et al13 found that the total 
milligram morphine equivalents for women discharged 
after vaginal delivery and after cesarean section 
ranged from 25 to 1200 and 50 to 1800, respectively. 
In a national study of opioid-naïve patients prescribed 
narcotics by an emergency department for treating 
ankle sprains, Delgado et al14 found prescribed ranges 
of 0 to 450 milligram morphine equivalents. These 
findings support our own and highlight that large 
variations in prescribing habits exist not only between 
trainee and attending physicians, but among all 
physicians across many specialties. 
The cause of the large variation in prescribing 
is likely multifactorial. Despite the current opioid 
epidemic and recent guidelines of the Centers for 
Disease Control and Prevention,15 there are few 
standardized protocols for prescribing narcotics in the 
postoperative period. Although some postoperative 
pain protocols have been successful in reducing 
milligram morphine equivalents prescribed,16 it is 
challenging to define a sufficient quantity of narcotics 
for postoperative pain control after a given procedure. 
This is because of multiple variables including 
surgical procedure, surgical time, preoperative opioid 
exposure, use of non-narcotic agents, and patient 
variability in pain perception.17 For example, a recent 
review by Wojahn et al18 found that the number of 
opiate pills consumed after knee arthroscopy varied 
greatly. Among individuals who were undergoing 
meniscal repair, patients who smoked and those taking 
preoperative opioids were significantly more likely to 
take higher numbers of opiates (≥ 20 pills vs a median 
of 7 pills). Furthermore, a debate exists as to whether 
postoperative narcotics should be prescribed on the 
basis of a given procedure or by patient-specific 
opioid usage during hospital admission.12 This is further 
convoluted by the known differences in patient opioid 
consumption versus opioids prescribed.19 Although 
our findings revealed that about 75% of respondents 
stated they prescribe non-narcotic analgesia, it is 
still unknown whether prescribing or recommending 
over-the-counter acetaminophen and NSAIDs results 
in higher patient compliance with these medications. 
Despite these challenges, it appears clear that patients 
would benefit from more standardized postoperative 
pain protocols. We published a companion article that 
explores potential protocols.20
There are several limitations to our study. First, 
there may be larger disparities in what respondents 
stated they prescribe as opposed to what they actually 
prescribe because of the limitations of survey design. 
Furthermore, all orthopaedic subspecialties were 
queried and might account for some of the large 
variation. For example, a survey respondent who 
practices pediatric orthopaedics may be unfamiliar with 
studies regarding opioid consumption after arthroplasty. 
Although most studies quantify milligram morphine 
equivalents, our study limited our definition to 5-mg 
oxycodone tablets. This was intentional because we 
presumed that many of our prescribers were unfamiliar 
with milligram morphine equivalents conversion. This 
may limit the external validity of these data. We also 
did not query length of time for which a narcotic should 
be prescribed, which may have yielded more or less 
variability. Lastly, this study was limited to a single, 
high-volume academic tertiary institution. There may 
be differences in variability of prescribing at other 
academic centers or community hospitals. 
In light of the ongoing opioid epidemic, institutions 
may benefit from standardized postoperative pain 
protocols. Multimodal analgesia should be included in 
these protocols, including acetaminophen and NSAIDs, 
as well as preoperative discussions with patients 
regarding expectations to optimize postoperative 
pain control. Studies evaluating the benefits of a 
multisubspecialty postoperative pain protocol are 
currently underway, and future work dedicated to 
minimizing narcotic use remains paramount.
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Comparison of Narcotic Prescribing Habits Between Trainee and Attending Orthopaedic Surgeons

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Comparison of Narcotic Prescribing Habits Between Trainee and Attending Orthopaedic Surgeons

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