A Cross-Cultural Comparison of Analgesic Prescribing Patterns in Orthopedic Trauma

Abstract

Background: The extent of variation in analgesic prescribing following musculoskeletal injury between countries is poorly understood. Understanding how analgesic prescribing varies between countries and cultural contexts can inform both domestic prescribing and future policy. Our survey study aimed to evaluate how opioid and non-opioid prescribing by orthopedic residents varies by geographic context. Methods: Orthopedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia at academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions by conversion to Morphine Milligram Equivalents (MMEs), and we quantified the likelihood and dose of acetaminophen or a non-steroidal anti-inflammatory drug (NSAID) prescription. We constructed multivariable regressions with generalized estimation equations to describe differences in opioid and non-opioid prescription between countries based on prescriber and test case characteristics. Results: Compared to residents from the Netherlands and Haiti, U.S. residents prescribed more total MMEs per case overall (in MMEs, U.S.:383 [CI:331-435]; Netherlands:229 [CI:160-297]; Haiti:101 [CI:52-150], p<0.0001) as well as when analyses were stratified by anatomical site of injury. Similar results were obtained when examining MMEs prescribed per day, opioid prescription duration, and likelihood of opioid prescription. Residents from Haiti were more likely to prescribe non-opioids (OR 3.22 [CI:1.94-5.34], p<0.0001) compared to U.S. residents, and residents from the Netherlands nearly always prescribed non-opioids. When prescribing opioids, providers co-prescribed a non-opioid (acetaminophen or NSAID) in 345/603 (57.2%) of U.S., 152/152 (100%) of Dutch, and 69/97 (71.1%) of Haitian cases (Fisher's exact test p-value <0.0001). Finally, providers prescribed only non-opioids for pain control in 3/348 (0.86%) of U.S., 32/184 (17.4%) of Dutch, and 107/176 (60.8%) of Haitian cases (Fisher's exact test p<0.0001). Conclusions: Our results demonstrate greater post-operative discharge opioid prescribing in the U.S. compared to at least 2 other countries, one low-income and one high-income. Additionally, U.S. prescribers prescribed non-opioid analgesics less frequently, either in isolation or in conjunction with opioids. Our findings highlight the high domestic reliance on opioid prescribing for post-operative pain in orthopedic trauma.