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Patient understanding regarding opioid use in an orthopaedic trauma surgery population: a survey study

Background Prior studies have assessed provider knowledge and factors associated with opioid misuse; similar studies evaluating patient knowledge are lacking. The purpose of this study was to assess the degree of understanding regarding opioid use in orthopaedic trauma patients. We also sought to determine the demographic factors and clinical and personal experiences associated with level of understanding. Methods One hundred and sixty-six adult orthopaedic trauma surgery patients across two clinical sites of an academic institution participated in an internet-based survey (2352 invited, 7.1% response rate). Demographic, clinical, and personal experience variables, as well as perceptions surrounding opioid use were collected. Relationships between patient characteristics and opioid perceptions were identified using univariate and multivariable logistic regressions. Alpha = 0.05. Results Excellent recognition (> 85% correct) of common opioids, side effects, withdrawal symptoms, and disposal methods was demonstrated by 29%, 10%, 30%, and 2.4% of patients; poor recognition (< 55%) by 11%, 56%, 33%, and 52% of patients, respectively. Compared with white patients, non-white patients had 7.8 times greater odds (95% confidence interval [CI] 1.9–31) of perceiving addiction discrepancy (p = 0.004). Employed patients with higher education levels were less likely to have excellent understanding of side effects (adjusted odds ratio [aOR] 0.06, 95% CI 0.006–0.56; p = 0.01) and to understand that dependence can occur within 2 weeks (aOR 0.28, 95% CI 0.09–0.86; p = 0.03) than unemployed patients. Patients in the second least disadvantaged ADI quartile were more knowledgeable about side effects (aOR 8.8, 95% CI 1.7–46) and withdrawal symptoms (aOR 2.7, 95% CI 1.0–7.2; p = 0.046) than those in the least disadvantaged quartile. Patients who knew someone who was dependent or overdosed on opioids were less likely to perceive addiction discrepancy (aOR 0.24, 95% CI 0.07–0.76; p = 0.02) as well as more likely to have excellent knowledge of withdrawal symptoms (aOR 2.6, 95% CI 1.1–6.5, p = 0.03) and to understand that dependence can develop within 2 weeks (aOR 3.8, 95% CI 1.5–9.8, p = 0.005). Conclusions Level of understanding regarding opioid use is low among orthopaedic trauma surgery patients. Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02881-w.

many patients are first exposed to opioids after undergoing a surgery and surgeons are amongst the highest prescribers of opioids [2,3], there has been a push within surgical specialties to educate physicians and their patients on the appropriate use of opioids. These efforts have largely targeted prescribing practices to reduce prescription size without increasing the need for refills due to poor pain management [4,5]. The Centers for Disease Control suggest early successes from such efforts, estimating a 17% decrease in prescription opioid-involved death rates from 2017 to 2019 [1]. However, recent data demonstrate an increase in overall overdose deaths coinciding with the start of the coronavirus disease (COVID-19) pandemic with over 81,000 deaths occurring in the year ending in May 2020 [6]. While there is some improvement in prescription opioid-related deaths, long-term use of opioids after surgery remains high [2,3]. To aid surgeons in understanding patients' risk of chronically using opioids, previous studies have assessed factors that may predispose individuals to opioid abuse after procedures [7,8]. These studies have suggested younger age, female sex, lower income, and specific medical comorbidities (i.e. pre-surgical opioid use, history of substance abuse, and mental health factors) can predispose patients to prolonged opioid use [9][10][11][12]. Knowledge of appropriate opioid use is also likely to play a role. Most literature addressing opioid knowledge has focused on providers' understanding [13][14][15]. However, the level of patient understanding regarding opioids and their appropriate use has been minimally studied [16][17][18][19]. Specifically, opioid knowledge within the orthopaedic trauma patient population, one of the populations most at risk for opioid misuse [10], has not previously been studied.
A study within an orthopaedic hand surgery specialty practice revealed that while 80% of patients are aware of the addictive properties of opioids, a substantial proportion also possess inaccurate beliefs, such as believing that opioids work well for controlling long-term pain [20]. Given the evidence of existing knowledge gaps, it is essential to identify the specific shortcomings in patient knowledge and to determine what demographic, clinical, or personal experience factors may be associated with misconceptions of opioid use. This information will provide a foundation on which to base future educational interventions.
We therefore sought to assess the degree of understanding regarding opioid use in a consecutive sample of orthopaedic trauma patients and identify knowledge gaps. We also aimed to determine the demographic, clinical, and personal experience factors associated with level of understanding.

Study design and settings
After institutional review board approval, participants were recruited from orthopaedic surgery trauma clinics at two hospital-based clinical sites within our institution. A consecutive sample of all adult patients (≥ 18 years) who visited the identified clinics between August 2009 and November 2020 were invited to participate via an email from the electronic medical record. Informed consent was obtained prior to administering an anonymous 32-question, voluntary online survey with a 7.4 grade Flesch-Kincaid reading level ("Appendix") [21,22]. The survey was created using Qualtrics XM (Seattle, WA, USA) and distributed via the MyChart system (Epic Systems Corporation, Verona, WI) to patients meeting our inclusion criteria, 2352 of whom opened the message. The study was performed using the MyChart system, rather than in-person surveys, due to restrictions on in-person research related to the COVID-19 pandemic.
The survey included questions about the following demographic variables: gender, age, race/ethnicity, insurance status, education level, employment status, marital status, and zip code to assess area deprivation index (ADI) quartile [23]. Participants were also asked to answer questions regarding clinical and personal experience with opioid use: chronicity of the injury/ accident/problem prompting the clinic visit; whether they underwent surgery; whether they received pain medication prescription, opioid prescription, opioid disposal instructions, or naloxone prescription; whether they were currently using opioids at the time of response, and whether they personally knew someone who has been dependent or overdosed on opioids.

Study population
Seven percent of patients who opened the message (166 of 2352) completed the survey. Sixty-seven percent of the respondents (111 of 166) identified as female, 31% (52) identified as male, and 2% (3) preferred to not provide their gender (Table 1).

Primary and secondary outcomes
Our primary study outcome was to assess trauma patients' understanding of opioid use. We defined understanding as correct identification and recognition of common opioids, suboxone/subutex, side effects, withdrawal symptoms, and appropriate disposal methods. Secondary outcomes were beliefs regarding time to dependency, safety of using over the counter (OTC) pain medications with opioids, comfort using naloxone, subjective pain level requiring opioid use, harmful effects of opioids, and confidence in their knowledge to safely manage opioid use. We also assessed addiction perception (whether others versus self can become addicted), with a discrepancy meaning they believe that others but not self can become addicted.

Statistical analysis
Survey data were analysed using descriptive statistics. Associations between demographics and clinical or personal experiences with variables assessing opioid understanding were explored using univariate and multivariable logistic regression (Additional file 1: Table S1, Table 3). The following potential confounders were included in the adjusted model: gender, age, race, marital status, employment status stratified by education level, ADI quartile, injury chronicity, prior opioid prescription, current opioid use, prior naloxone prescription, and knowing someone who has been dependent or addicted on opioids. Analyses were performed using Stata, version 16.0, software (StataCorp LLC, College Station, TX). Alpha was set at 0.05.

Current level of patient understanding regarding opioid use
Excellent recognition was defined as > 85%, poor as < 55% items identified correctly. Twenty-nine percent of patients (48 of 166) demonstrated excellent recognition of common opioids. Ten percent (17) had excellent recognition of side effects, 30% (50) withdrawal symptoms, and 2.4% (4) appropriate disposal methods. While 11% of patients (18) had poor recognition of common opioids, 56% (93), 33% (54), and 52% (86) poorly recognized side effects, withdrawal symptoms, and disposal methods, respectively (Fig. 1). Further, 34% (56) believed dependence takes weeks to months to develop, and 18%  (30) were uncomfortable using naloxone. While patients almost unanimously understood that opioids are harmful and that others can become addicted, 11% (19) had a discrepancy in addiction perception. Almost all patients (88%) stated that they would only take an opioid for moderate to severe pain, defined as a score ≥ 5/10 on the visual analog scale. Eighty-six percent of patients (143) believed they currently know enough to take opioids safely ( Table 2).  (Table 3).

Clinical and personal experiences associated with level of understanding
Patients currently using opioids had 5.2 times greater odds (95% CI 1.0-27) of understanding that it is safe to take opioids with OTC pain medications (p = 0.046). Patients who knew someone who was dependent or overdosed on opioids were significantly less likely to believe that others but not self can become addicted (aOR 0.24, 95% CI 0.07-0.76; p = 0.02). They also possessed greater knowledge regarding withdrawal symptoms (aOR 2.6, 95% CI 1.1-6.5, p = 0.03) and were more likely to understand that dependence can develop within 2 weeks of initiating opioids (aOR 3.8, 95% CI 1.5-9.8, p = 0.005). No other clinical or personal experiences were significantly associated with level of patient understanding (Table 3).

Discussion
The safe prescribing of opioids is a critical issue in medicine and especially for orthopaedic trauma surgery. It is crucial to understand and improve the level of patient understanding regarding the use of opioids to improve our care of patients. Our study illustrates that there are significant gaps in understanding and concerning patterns of beliefs regarding opioid use for orthopaedic trauma surgery patients, even amongst a predominantly high socioeconomic status population. While our respondents had a fairly strong recognition of common opioids, they had a poor understanding of side effects, withdrawal symptoms, and appropriate disposal methods. One potential explanation may be that commercial media has improved public recognition of common opioids, but awareness of their medical implications is still lacking [24,25] This theory is further supported by our results illustrating greater identification of side effects, such as addiction (87%) and constipation (78%), that have received more media attention [26].
Our study demonstrates the need for additional education of all our patients in several areas. A subset of the respondents believe that they cannot become addicted to opioids, even when they recognize the addictive potential for others. This is consistent with the results of previous studies, which have shown inaccurate perception of individual risk may be due to addiction stigma or the perception that addiction is a moral failing that can be resisted through personal willpower [27][28][29]. Patients also lacked knowledge about the rapid nature of opioid dependence and naloxone use [30,31]. Patients had a better understanding of dependence and appropriate dosing, as over half of our patients understand that dependence can occur within 2 weeks and patients almost universally would not take an opioid for mild pain levels. This may demonstrate early successes with patient education on opioid use.
We found that race was independently associated with level of understanding, with patients identifying as white being significantly less likely to have discrepancy in addiction perception [32,33]. This may be attributed to an awareness that the most dramatic increase in overdose mortality in the last two decades occurred amongst non-Hispanic whites [34,35]. Much of the recent social and political attention on the opioid epidemic has also been focused on this population [36,37]. While use amongst whites has been framed as a public health crisis, the media has traditionally portrayed blacks with opioid use disorders as having a moral shortcoming and undergoing greater criminalization [36]. Minorities thus may have alternative perceptions regarding opioid use and selfaddiction. However, our findings cannot be confidently interpreted without more robust quantitative studies that do not use race as a surrogate for other factors (i.e., health behaviours).
We further illustrated that employment with higher education level and being from the least disadvantaged ADI quartile were associated with lesser levels of knowledge regarding opioid use when controlling for potential confounders. This contrasts with the results of Bargon et al. [20], who demonstrated higher education to be associated with patients understanding the importance of opioid prescribing policies, suggesting greater knowledge of opioid misuse. This conflicting and limited evidence emphasizes the necessity for further studies evaluating patient knowledge of opioids in orthopaedic surgery. Our findings may reflect that patients of lower socioeconomic measures and from more disadvantaged geographic regions are more frequently exposed to opioid prescription, chronic consumption, and related overdose in their communities [38][39][40][41]. This exposure, in turn, may translate to greater knowledge regarding opioids.
In addition, patients had significantly greater levels of understanding if they were currently using opioids or knew someone who misused opioids. This aligns with OTC, Over the counter a Percentages may not add to 100 from rounding error  Gender the results of Razdan et al., who determined that knowledge regarding opioid use for paediatric patients was greater for parents who knew someone who had become addicted to opioids [42]. Stover et al. [43] also demonstrated that young adults who received prior naloxone training or opioid prescriptions scored significantly higher on the Opioid Overdose Knowledge Scale. It is possible that these patients were educated by their prescribing physician or distributing pharmacist on the appropriate use and risks involved. Another plausible explanation is that in light of the ongoing opioid epidemic, patients were more aware of the intrinsic risks and more inclined to research these risks upon receiving prescriptions or having someone they know become dependent or overdosing on opioids [43]. Recent initiatives to educate patients through counseling and public materials thus may be effective, and it is important for surgeons to follow recommendations for co-prescription of naloxone and opioids. Altogether, these results suggest that clinical and personal experience with opioids should be emphasized when taking patient histories, and those with positive histories may be more knowledgeable in the appropriate use and risks of taking prescription opioids in the postoperative period. Our study is not without limitations. The electronic format of our survey distribution was a result of the COVID-19 pandemic, which restricted access to patient care areas (i.e. trauma clinics). Subsequently, the study was limited by responder bias with the low response rate. Responders likely differ from non-responders, especially since the survey's electronic format tends to attract more white responders possessing higher socioeconomic measures [44,45]. As a result, the respondents did not accurately represent the trauma patient population seen by our institution, which serves a clinically diverse, minority-majority patient population within an urban environment. However, it must be noted that the response rate was based on the 2352 patients who opened the survey invitation, thereby controlling for internet access and associated socioeconomics to an extent. Respondents also likely had more personal experiences with opioids which motivated them to answer the survey. Despite the high socioeconomic measures of our cohort, we were able to capture 17 unique individuals (10%) who reported self-dependency or overdose on opioids, which is higher than the estimated national rate of prescription opioid misuse (3.6%) amongst people aged 12 years or older [46]. Overall, our respondent characteristics would trend toward greater awareness of opioids and the importance of understanding their appropriate use [20,43], so the low level of understanding in our results likely overestimates opioid knowledge, emphasizing the importance of presenting our findings.

Conclusions
In conclusion, all prescribers should be aware that there is a low level of understanding regarding opioid use in patients who present to orthopaedic trauma surgery clinics. This places patients at higher risk for misusing opioids if prescribed. It is essential to emphasize that providers should not exacerbate existing prescribing disparities and reduce access to opioids for patients with lesser understanding. Rather, more involved educational interventions should be taken with these patients to mediate risk for misuse, and improvements in overall patient education should be established at all institutions. To more comprehensively study patient understanding, future studies should apply larger scale, multidisciplinary, multicenter surveys and investigate the effectiveness of specific educational interventions in improving patient knowledge. Application of robust qualitative methods grounded in well-established social theories, like the Health Belief Model, which is outside the scope of this study, would be better able to provide reasons behind the perceptions assessed here as well.
Bold values indicate significant associations between patient characteristics and measures of understanding regarding opioid use OTC, Over the counter; ADI, area deprivation index *Significant at p < 0.05 **Significant at p < 0.01 ***Significant at p < 0.001 a Addiction discrepancy = patients who believed that others, but not self, can become addicted to opioids b Referent