Canada

North America is at the heart of the opioid crisis, with Canada and the USA leading in the per-person consumption of prescription opioids globally [7]. The opioid crisis primarily emerged due to the insufficient regulation and profit-driven motives of the pharmaceutical and healthcare industries, which nearly quadrupled opioid prescribing [7]. There were 22,828 deaths from opioid toxicity between 2016 and 2021 in Canada, with 6,946 deaths occurring during the COVID-19 pandemic between April 2020 to March 2021 [8].

The Netherlands

In the Netherlands, between 2008 and 2017, the cumulative number of opioid prescriptions nearly doubled, with a concordant increase in misuse [9]. Between 2007 and 2016, deaths caused by opioid overdose in Europe were 1.2 deaths per 100000 per year, compared to 15 deaths per 100000 in the USA [10]. Opioid misuse in the Netherlands is substantially lower than in North America, including opioid-related mortality, though it is much greater than in Japan [9,11]. Concerns about opioid use in the Netherlands are predominantly due to marketing by pharmaceutical companies directed to the surgeon, and surgeon preferences [9].

Japan

The per capita use of six potent opioids is 26 times higher in the USA than in Japan despite a similar prevalence of chronic pain. Orthopaedic surgeons in Japan prescribe significantly fewer postoperative opioids compared to North America [4]. Japan was the first Asian country to enact modern legislation in the 19^th century to regulate opioid consumption strictly [4,12]. Therefore, in the last couple of decades, Japan has not experienced substantial issues with opioid addiction and related consequences [4].

Rationale

Comparing and understanding perceptions of facilitators and barriers to reducing the use of opioids in distinct jurisdictions may inform the willingness of surgeons to revisit their prescribing practices. It may also aid in identifying potential best practices that can be shared among countries to enhance patient outcomes and promote safer pain management practices. We therefore conducted a qualitative study to explore: (1) perceptions of opioid prescribing after joint replacement, and (2) facilitators and barriers to opioid reduction after TKA or THA in three jurisdictions that represent high (Canada), moderate (The Netherlands), and low (Japan) opioid prescribing practices.

Research design

We used a qualitative description design, commonly employed to provide descriptive accounts of health care phenomena. Qualitative description methodology emphasizes an analytical and data-driven perspective to prioritize the practical implications of findings for healthcare providers, educators, and policymakers [13–16].

Sampling and recruitment

Surgeons from Canada, the Netherlands, and Japan were sampled. We recruited surgeons who understood and spoke English and routinely performed hip or knee arthroplasty via convenience sampling. This entailed contacting surgeons within our personal and professional networks who we knew either prescribed or did not prescribe opioids. We used non-probability, purposive sampling to intentionally “select” participants who could provide a rich account of the phenomena of interest [16,17]. We also used snowball recruitment, where initial participants recommended additional contacts in the same country who fit the research criteria and were willing to partake in the study. We sought maximum variation in academic versus community practice locations, gender, and years of practice. We also recruited participants via our professional social media accounts (i.e., Instagram and Twitter) and email.

Interview guide

We used a semi-structured interview guide, which consisted of a series of open-ended questions to capture the perceptions of surgeons on barriers and facilitators to reduced opioid prescribing after discharge following TKA or THA (S1 File). The research objectives, the team members’ clinical experiences and perceptions of important topics, and past literature concomitantly informed the development of this interview guide [18,19].

Data collection

Trained research assistants conducted semi-structured interviews via Zoom or phone with 11 Canadian, 9 Dutch, and 7 Japanese orthopaedic surgeons. One interview with a Dutch surgeon included an anesthesiologist as well. We provided Japanese surgeons with an option to access a translator if needed. Data saturation was reached after no new themes were developed from data analysis, and we completed two subsequent interviews in each country to verify [16]. Interviews were completed between November 2022 and February 2023, lasting between 15–45 minutes. Each interview was audio-recorded, transcribed verbatim, and de-identified for data analysis. Prior to data collection, participants were provided with a research ethics board (REB)-approved information letter that described the study in accessible language and provided sufficient information for participants to make an informed decision about their participation. They were given ample time to review and ask questions. Thereupon, verbal informed consent was obtained during the interview and documented on a REB-approved verbal informed consent log for audio and/or video recording and the use of quotes. This study was reviewed and approved by the Hamilton Integrated Research Ethics Board (Project number 15023; McMaster University).

Data analysis

Data analysis involved conventional (inductive) content analysis [14,20,21]. We collected and analyzed data concurrently. Two research team members iteratively read the transcripts to derive codes by highlighting text that captured key thoughts or concepts. Subsequently, labels for codes were actively constructed from the text and formed the initial coding scheme. We grouped the codes into categories based on their relationships and connections, which helped organize codes into meaningful groups [20]. To ensure the authenticity and completeness of the identified concepts and their overarching categories, two members coded all transcripts independently and in duplicate in a triangulated approach. We also captured representative quotes for the identified categories.

To compare themes in each country, we used an integrated, joint, side-by-side display [22]. We illustrated concepts in Venn diagrams to identify similarities and differences between jurisdictions. We summarized demographic data using ranges and proportions. We used Dedoose (v9.0.90) for data management and analysis.

Strategies to promote rigor and trustworthiness

The term “bias” is generally drawn from quantitative research and is incompatible with the philosophical underpinnings of qualitative methodology as the subjectivity resulting from the researcher is integral to qualitative research [15]. Accordingly, to enhance the credibility of the data, the research team comprised expert qualitative researchers, orthopaedic surgeons, an experienced orthopaedic research coordinator, and experts in chronic pain management. The team had peer debriefing meetings to ensure conceptual ideas were explored and well-organized. We also used triangulation to enhance the trustworthiness of our findings [23]. We used member checking, where we asked participants to check the completeness of the summary of findings based on their responses at the end of the interview. The interviewers also developed positionality statements (S2 File), and kept a field diary and a reflective journal to ensure interpretive authority [24]. Potential power imbalances were minimized as interviews were conducted by graduate and undergraduate students with no authority or influence over participants’ careers.

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S4 File).

Characteristics of participants

Out of the 27 participants in the study, the majority were men (n = 21, 78%) (Table 1). The length of surgical practice varied, ranging from less than one year to 28 years. Sixty-three percent of included surgeons practiced in academic settings. In-hospital stay post-operation was 0–3 days for both TKA and THA in Canada and the Netherlands, and 10–30 days in Japan. Interviewed surgeons in Canada and the Netherlands reported that all or almost all their patients were prescribed opioids after discharge. In contrast, surgeons in Japan showed much greater variability, with half prescribing opioids to all patients and the other half prescribing opioids to only a minority or no patients after discharge. In addition, during interviews, Canadian and Dutch orthopaedic surgeons indicated use of a wider range of opioids as compared to Japanese surgeons, who predominantly prescribed NSAIDs and tramadol (S3 File).

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Table 1. Demographic and practice characteristics of participating orthopaedic surgeons in Canada, The Netherlands, and Japan.

https://doi.org/10.1371/journal.pone.0331335.t001

We grouped data on barriers and facilitators to opioid reduction into six categories (S3 File, S1 and S2 Figs). Examples of quotes representing each theme can be found in Table 2.

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Table 2. Categories of barriers and facilitators to reduced opioid prescribing identified by surgeons.

https://doi.org/10.1371/journal.pone.0331335.t002

Category 1: Surgeons’ prescribing practices

We identified several facilitators to opioid reduction emerging from surgeons’ interview responses (S3 File, S1 and S2 Figs). Canadian and Dutch surgeons included in our study stated that they had decreased the quantity and duration of opioid prescriptions over time, with many currently prescribing opioids as-needed. Moreover, during interviews, Canadian and Dutch surgeons shared concerns about misuse and the adverse effects of opioids, specifically addiction. Conversely, Japanese surgeons expressed apprehension about additional side effects, such as falls, sedation, nausea, constipation, and hepatic dysfunction, in addition to addiction. Many Japanese surgeons interviewed in this study believed that opioids were not necessary for pain management after discharge and preferred to use non-opioid alternatives such as NSAIDs or paracetamol. However, half of the Japanese surgeons we interviewed prescribed tramadol to all their patients on discharge. Meanwhile, in the Netherlands, all included surgeons described using a standard institutional protocol for postoperative/discharge pain management, which reduced variations in prescribing practices among colleagues.

Participating surgeons in all three countries reported encountering several barriers and challenges to opioid reduction. Dutch and Canadian surgeons highlighted the tension they faced between the need to relieve patients’ pain and preserve their mobility while minimizing the risks of opioid use. These surgeons also noted that busy schedules hindered their ability to monitor patients’ opioid use. Although many Dutch surgeons who were interviewed followed standard institutional protocols for postoperative and discharge prescribing, some surgeons were unfamiliar with the specific details because anesthesiologists handled postoperative pain management at some institutions. However, most Canadian and Japanese orthopaedic surgeons in our study did not describe using a standard institutional protocol. Many Canadian surgeons perceived that senior orthopaedic surgeon exhibited resistance to reducing opioids and had outdated prescribing practices. They also pointed out that differences in individual surgeons’ preferences, experiences, and training may explain variations in prescribing practices.

Category 2: Patient factors

All Dutch and Canadian orthopaedic surgeons interviewed in our study reported that either they or a member of the care team provided patients with pre- and postoperative education about pain expectations, medications, and potential side effects (S3 File, S1 and S2 Figs). Dutch surgeons also described offering education about the pain management ladder, which prioritizes non-opioid analgesics first and strategies for tapering opioid use. Some Japanese surgeons did not provide patient education regarding analgesia as they believed it was only necessary when prescribing strong opioids. Orthopaedic surgeons in Japan noted that cultural factors led to resistance to opioid use among some Japanese patients, who preferred non-opioid pain management options.

Canadian and Dutch participants shared concerns about the potential for patients to divert unused opioids; however, most surgeons reported that they did not provide instructions to patients about how to properly dispose of unused opioids. Surgeons in both countries expressed concerns about patient dissatisfaction with reduced quantity/dosage of opioids and the use of non-opioid pain management modalities. Canadian and Dutch surgeons also noted that patients frequently harbored unrealistic expectations of being entirely pain-free following surgery, making it challenging to decrease opioid prescribing.

Category 3: Collaborative care

Orthopaedic surgeons from Canada and the Netherlands interviewed in this study reported collaborations with other healthcare providers, pain clinics, and pharmaceutical departments to enhance patient care and education, to receive education on opioid prescribing, and to develop a standardized pain management protocol within their institutions (S3 File, S1 and S2 Figs). These collaborations also aimed to provide optimal care for patients with substance use disorders.

Many orthopedic surgeons that we interviewed shared apprehensions about patients obtaining opioid refills from other healthcare providers without their knowledge or authorization. Also, Canadian surgeons expressed challenges with referring patients to pain clinics for more specialized care as these clinics often had long wait times. In contrast, many Japanese surgeons described that their institution lacked a specialized pain management team, making it challenging for them to refer patients with greater needs to professionals who are more experienced in managing pain. Dutch surgeons in our study described inconsistencies in opioid prescribing patterns and attitudes among healthcare professionals within a patient’s care team, especially if providers other than the surgeon were involved in prescribing.

Category 4: Policies, guidelines, and regulations on opioid prescribing

During the interviews, many Canadian surgeons identified provincial campaigns on opioid reduction and institutional regulations and monitoring as facilitators of opioid reduction (S3 File, S1 Fig). Notably, some Canadian surgeons perceived reluctance in the orthopaedic community to prescribe opioids due to fear of litigation or license suspension. Moreover, some Japanese surgeons in our study highlighted that regulations on more potent opioids restricted their ability to prescribe them. However, most Canadian and Japanese surgeons lacked knowledge about existing guidelines for opioid prescribing (S2 Fig). Some Canadian surgeons believed that current policies and guidelines on peri-operative opioid use were outdated. Some also felt that the strict opioid prescribing policies and restrictions placed pressure on them and hindered their ability to provide individualized care, particularly for patients experiencing severe pain.

Category 5: Opioid risk mitigation via continuing surgeon education

Included orthopaedic surgeons from all three countries discussed their experiences and perspectives on continuing education regarding safer opioid prescribing (S3 File, S1 and S2 Figs). Some Canadian and Dutch orthopedic surgeons were actively involved in opioid-related research and were members of arthroplasty or orthopedic groups and societies. Others recalled receiving institutional/departmental training on pain management and opioid prescribing (i.e., through modules, meetings, rounds, and conferences). Conversely, while some Japanese institutions provided additional training and guidance on opioid prescribing, many interviewed surgeons reported completing external e-learning modules for every type of opioid that they prescribed.

During interviews, some surgeons in all three countries stated that they had not received any specific education on opioid prescribing after their medical training. While some of these surgeons did not see the need for further education, others recognized its importance. For example, Canadian surgeons emphasized the need for more education on identifying abuse, pain management for vulnerable populations, dosing, non-opioid alternatives, and prescribing trends, with a preference for online and short educational sessions. Likewise, Dutch surgeons in our study identified a need of formal education on available multimodal pain management protocols, relevant literature updates, novel products, and emerging non-opioid alternatives. Japanese surgeons highlighted the need for education on risk factors for substance use disorder and postoperative pain management strategies for patients at risk of substance use disorders.

Category 6: Personal perceptions and beliefs towards opioid prescribing

Orthopaedic surgeons that we interviewed from Canada, the Netherlands, and Japan had varying perceptions of opioid prescribing, but some similarities were observed (S3 File, S1 Fig). Many Canadian and Dutch surgeons believed that opioids are necessary for improving patients’ sleep and mobility and, subsequently, cannot be eliminated from post-THA/TKA pain management protocols. Almost all Japanese orthopaedic surgeons that we interviewed considered tramadol less addictive than other opioids, but some desired more potent and longer-duration opioids. Many included surgeons from Japan and the Netherlands exhibited knowledge gaps and uncertainty regarding the use of opioids for patients with substance use disorders.

Strengths

Our study provides a cross-cultural understanding of opioid prescribing practices by exploring the perspectives of orthopedic surgeons across three countries that represent high (Canada), moderate (the Netherlands), and low (Japan) opioid prescribing practices. The qualitative approach allows for an in-depth exploration of nuanced barriers and facilitators that may not be captured through quantitative methods. Additionally, we implemented triangulation and member checking to enhance the trustworthiness of our findings.

Limitations

Our study involved surgeons who volunteered to participate and, thus, may have had a heightened interest or stronger perceptions regarding opioid use and prescribing. Also, there were considerably more men than women participants in our study, likely reflecting the under-representation of women in arthroplasty in all three countries of interest [46]. Our results may not be transferable to other settings due to differences in population makeup and cultures. Moreover, our sample primarily consisted of surgeons practicing in academic settings, which may stem from inherent limitations in convenience and snowball sampling. As qualitative studies seek to understand a specific phenomenon, generalizability is not an expected attribute as it is for quantitative studies. Additionally, interviews were conducted in English, which may have created comprehension difficulties for some Japanese surgeons. However, we provided the option of a translator if necessary. Although there is a potential for social desirability bias in participants’ responses, we endeavored to minimize this bias by ensuring that there were no leading questions, using indirect questioning, probing and clarifying participant responses, and providing assurance of confidentiality and anonymity prior to commencing the interviews [47].