Opioid Consumption Following Foot and Ankle Surgery

Postoperative Opioid Usage and Disposal Strategies After Arthroscopic Procedures in a Young Cohort: A Prospective Observational Study

Background

Although several studies have noted that patients are routinely overprescribed opioids, few have reported usage after arthroscopic surgery.

Purpose

To determine opioid consumption and allocation for unused opioids after common arthroscopic surgeries.

Study Design

Case series; Level of evidence, 4.

Methods

Patients between the ages of 15 and 40 years who were scheduled to undergo anterior cruciate ligament reconstruction (ACLR), labral repair of the hip or shoulder, meniscectomy, or meniscal repair were prospectively enrolled. Patients were prescribed either 5 mg hydrocodone-325 mg acetaminophen or 5 mg oxycodone-325 mg acetaminophen based on surgeon preference. Patients completed a daily opioid usage survey during the 2-week postoperative period. In addition, patients completed a survey on postoperative day 21 inquiring about continued opioid use and medication disposal, if applicable. Opioid medication consumption was converted to morphine milligram equivalents (MMEs).

Results

Of the 200 patients who were enrolled in the study, 176 patients had sufficient follow-up after undergoing 85 (48%) ACLR, 26 (14.8%) hip labral repair, 34 (19.3%) shoulder labral repair, 18 (10.2%) meniscectomy, and 13 (7.4%) meniscal repair procedures. Mean age was 26.1 years (SD, 7.38); surgeons prescribed a mean of 26.6 pills whereas patients reported consuming a mean of 15.5 pills. The mean MME consumption in the 14 days after each procedure was calculated: ACLR (95.7; 44% of prescription), hip labral repair (84.8; 37%), shoulder labral repair (57.2; 35%), meniscectomy (18.4; 27%), and meniscal repair (32.1; 42%). This corresponded to approximately 39% of the total opioid prescription being utilized across all procedures. Mean MME consumption was greatest on postoperative day 1 in hip, shoulder, and meniscal procedures and on postoperative day 2 in ACLR. Only 7.04% of patients reported continued opioid use in the third postoperative week. Patients had a mean of 11 unused pills or 77.7 MMEs remaining. Of the patients with remaining medication, 24.7% intended to keep their medication for future use.

Conclusion

The results of our study indicate that patients who undergo the aforementioned arthroscopic procedures consume <75 MMEs in the 2-week postoperative period, translating into a mean of 10 to 15 pills consumed. Approximately 60% of total opioids prescribed went unused, and one-fourth of patients intended to keep their remaining medication for future usage. We have provided general prescribing guidelines and recommend that surgeons carefully consider customizing their opioid prescriptions on the basis of procedure site to balance optimal postoperative analgesia with avoidance of dissemination of excess opioids.

Intravenous injection of dexamethasone is non-inferior to perineural administration for popliteal sciatic nerve and saphenous nerve blocks: A randomized, controlled, triple-blind study

Background

The aim of this study was to assess whether intravenous dexamethasone was noninferior to perineural dexamethasone as an adjuvant to ropivacaine for a combination of saphenous and sciatic nerve blocks in patients undergoing foot and ankle surgery.

Methods

This was a prospective, blinded, randomized noninferiority study. Seventy-five patients, aged 18-75 years, with an American Society of Anesthesiologists (ASA) physical status I-III who underwent foot and ankle surgery were involved. Patients scheduled for ultrasound-guided popliteal sciatic nerve block and saphenous nerve block were randomized to receive 0.375% ropivacaine with 7.5 mg of dexamethasone perineurally (Dex-PN), 10 mg of dexamethasone intravenously (Dex-IV) or neither (Placebo). The primary outcome was the duration of analgesia. The major secondary outcomes were the composite pain intensity and opioid consumption score at 0-48 h intervals after anesthesia.

Results

The mean analgesic duration was 26.2 h in the Dex-IV group and 27.9 h in the Dex-PN group (duration difference, -1.7; 95% CI, -3.8 to 0.43; P = 0.117), and both durations were significantly longer than that in the placebo group (17.6 h, P < 0.001). Conditions for establishing non-inferiority were met.

Conclusions

Our findings indicate that a single 10-mg intravenous dose of dexamethasone was noninferior to the combined dose of ropivacaine plus deaxmethasone in terms of duration of analgesia for foot and ankle surgery.

Preoperative Opioid Use Predicts Poorer Outcomes of Total Ankle Arthroplasty and Hindfoot Fusions

BACKGROUND

This study aimed to determine the impact of preoperative opioid use on outcomes of patients undergoing ankle or hindfoot arthrodesis, or total ankle arthroplasty (TAA).

METHODS

We conducted a retrospective review of 190 patients undergoing an ankle or hindfoot arthrodesis (n=122) or TAA (n=68) between December 2015 and September 2020 with a single fellowship-trained orthopaedic foot and ankle surgeon at an academic medical center. Data collected included demographics, medical comorbidities, treatment history, complications and reoperation rates, patient-reported outcome measures (PROMs) (eg, Foot and Ankle Outcome Score [FAOS]), and opioid use.

RESULTS

Patients with preoperative opioid use were more likely to continue usage at 90 (r = 0.931, P < .001) and 180 (r = 0.940, P < .001) days postoperatively. For the entire cohort, complication and reoperation rates were 48.9% and 13.2%, respectively. While preoperative opioid use groups did not differ in the overall complication rate, users had significantly more infections (user = 12.5%, nonuser = 3.3%; P = .036) and reoperations (user = 22.5%, nonuser = 10.7%; P = .049). When analyzing postoperative opioid prescriptions, there were many significant correlations with preoperative PROMs, mainly FAOS, such that increased postoperative opioid use was associated with worse subjective outcomes.

CONCLUSION

Preoperative opioid users are more likely to continue postoperative opioid use, experience infections, and undergo reoperations.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Strategies for Reducing Perioperative Opioid Use in Foot and Ankle Surgery: Education, Risk Identification, and Multimodal Analgesia

There remains a high prevalence and substantial risks of opioid utilization amongst orthopedic patients. The goal of this review is to discuss strategies for responsible opioid use in the perioperative setting following foot and ankle orthopedic surgeries. We will highlight 1) education interventions, 2) risk identification, and 3) non-opioid alternatives for postoperative pain management.

Risk Factors for Prolonged Opioid Use After Ankle Fracture Surgery

BACKGROUND

The incidence of ankle fractures is increasing, and risk factors for prolonged opioid use after ankle fracture fixation are unknown. Accordingly, the purpose of this study was to investigate risk factors that lead to prolonged opioid use after surgery.

METHODS

The Truven MarketScan database was used to identify patients who underwent ankle fracture surgery from January 2009 to December 2018 based on CPT codes. Patient characteristics were collected, and patients separated into 3 cohorts based on postoperative opioid use (no refills, refills within 6 months postoperative, and refills within 1 year postoperatively). The χ2 test and multivariate analysis were performed to assess the association between risk factors and prolonged use.

RESULTS

In total, 34 691 patients were analyzed. Comorbidities most highly associated with prolonged opioid use include 2+ preoperative opioid prescriptions (odds ratio [OR] = 11.92; P < .001), tobacco use (OR = 2.03; P < .001), low back pain (OR = 1.81; P < .001), depression (OR = 1.48; P < .001), diabetes (OR = 1.34; P < .001), and alcohol abuse (OR = 1.32; P < .001).

CONCLUSION

Opioid use after ankle fracture surgery is common and may be necessary; however, prolonged opioid use and development of dependence carries significant risk. Identifying those patients at an increased risk for prolonged opioid use can aid providers in tailoring their postoperative pain regimen.

LEVELS OF EVIDENCE

Prognostic, Level III.

Postoperative Opioid Consumption Following Hallux Valgus and Rigidus Surgery: A Guide to Postoperative Prescription Writing

Prescribing postoperative pain medications is essential to foot and ankle surgery; however, prescribing an amount that results in an excess of pills has shown to lead to opioid abuse. The opioid epidemic has forced surgeons to analyze how we manage postoperative pain with a goal to prescribe the optimal number of pills that will reduce a patient's pain while limiting the amount that is left over. The purpose of this study was to develop a guideline for prescribing postoperative pain medication for hallux valgus and rigidus procedures. One hundred eighty-five opioid naive patients were followed after undergoing surgery for hallux valgus or hallux rigidus. The number of opioids consumed was obtained and compared to a number of variables. There were 28 different prescriptions given during the study. As the number of pills given decreased, so did the number of pills consumed (p = .08). Of the 185 patients, 14 (7.56%) received a refill. Ninety-five patients were available for opioid consumption data analysis. Those patients consumed a median of 36.7% and 39.1% of their prescription for hallux valgus and hallux rigidus procedures respectively. Smokers consumed 2.4 times the number of narcotics compared to nonsmokers (p = .002). The median number of 5-325 mg hydrocodone-acetaminophen pills consumed was 8.5 for distal metatarsal osteotomies and 10 for first metatarsophalangeal joint procedures. Body mass index, gender, number of procedures performed did not have a statistical difference in the number of opioids taken. Foot and ankle surgeons can reduce the amount of excess opioids by decreasing the initial prescription and educating the patient on proper pain management modalities.

Opioid Use, Perioperative Risks, and Associated Postoperative Complications in Foot and Ankle Surgery

INTRODUCTION

Opioid abuse has become a national crisis. Published data demonstrate that patients undergoing foot and ankle surgery are left with excess narcotic medications postoperatively. The purpose of our study was to evaluate factors associated with prolonged postoperative opioid use following foot and ankle surgery and identify associations between preoperative opioid use and postoperative complications.

METHODS

MarketScan commercial claims and encounters database was searched to identify foot and ankle patients. Preoperative comorbidities were queried and documented. Patients utilizing opioids 1 to 3 months prior to surgery were identified. Adjusted odds ratios and 95% CIs were calculated using multivariable logistic regression to determine associations between opioid use (preoperatively and postoperatively), readmission, and complications.

RESULTS

A total of 112 893 patients were included in the study. Preoperative use had a statistically significant association with postoperative use out to 1 year. Tobacco use, chronic pain, mental health diagnosis, and nonopioid medications had a statistically significant association with postoperative use. Preoperative opioid use had a statistically significant association with readmission and postoperative complications.

CONCLUSION

Our study found a number of factors associated with prolonged postoperative opioid use (preoperative use, tobacco use, chronic pain, mental health disorders, and certain nonopioid medications). We identified an association between preoperative opioid use and postoperative complications and readmission.

LEVELS OF EVIDENCE

Prognostic Level IV Evidence.

Economic impact of Comorbidities in Total Ankle Arthroplasty and Ankle Arthrodesis

BACKGROUND

The demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is limited. The goal of this study is to study the comorbidity burden for TAA and ankle arthrodesis.

HYPOTHESIS

Comorbidity burden is associated with higher resource utilization for both TAA and ankle arthrodesis.

PATIENTS AND METHODS

This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on n=10,085 ankle arthrodesis and n=4,977 TAA procedures. Patients were categorized into Deyo-Charlson comorbidity index (DCCI) groups. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization, discharge to a skilled nursing facility (SNF), and 30-day readmission. Mixed-effects models estimated associations between DCCI and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI).

RESULTS

In the TAA group, 67.9% of patients were in DCCI category 0 while 22.4%, 6.6%, and 3.1% were in the 1, 2, and >2 DCCI categories, respectively. This was 61.3%, 18.1%, 9.8% and 10.9% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus, and chronic pulmonary disease. Particularly in the ankle arthrodesis group, the proportion of patients with comorbidities has increased over time. After adjustment for relevant covariates, patients in the DCCI group >2 (compared to '0') were associated with stepwise effects of up to 77.1% (CI 70.9%; 83.6%) longer length of stay and up to 48.5% (CI 44.0%; 53.2%) higher cost of hospitalization.

DISCUSSIONS

Comorbidity burden is increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status.

LEVEL OF EVIDENCE

III.

Perioperative Opioid Analgesics and Hallux Valgus Correction Surgery: Trends, Risk Factors for Prolonged Use and Complications

In the setting of an opioid epidemic, this study aims to provide evidence on opioid use trends, risk factors for prolonged use, and complications from perioperative opioid consumption in hallux valgus surgery. A national database was queried for patients who underwent hallux valgus correction. Regression analysis identified: (1) risk factors for prolonged postoperative narcotic use; and (2) association between preoperative/prolonged postoperative narcotic use and postoperative complications. A linear regression analysis was used to determine trends. About 20,749 patients were included, of which 3464 patients were prescribed narcotics preoperatively and 4339 were identified as prolonged postoperative narcotic prescription users. Preoperative prescriptions were identified as risk factors for prolonged use. Perioperative narcotic use was observed to be a risk factor for poor outcomes. About 21% of patients were identified as prolonged postoperative narcotic prescription users. Patients undergoing hallux valgus corrective surgery should be counseled regarding their increased risk of complications when using narcotics.

Postoperative Pain Medication Utilization in Pediatric Patients Undergoing Sports Orthopaedic Surgery: Characterizing Patient Usage Patterns and Opioid Retention

INTRODUCTION

Opioid overprescribing is a problem in orthopaedic surgery, with many patients having leftover opioid medications after surgery. The purpose of our study was to capture utilization patterns of opioids in pediatric patients undergoing orthopaedic sports medicine surgery, in addition to evaluating patient practices surrounding unutilized opioid medication. Our hypothesis was that there would be low utilization of opioids in this patient population and would in turn contribute to notable overprescribing of opioids and opioid retention in this population.

METHODS

Pediatric patients undergoing orthopaedic surgery for knee and hip pathology were prospectively enrolled. A survey was administered 14 days postoperatively, with questions centered on the patient-reported number of opioids prescribed, number of opioids used, number of days opioids were used, and incidences of leftover opioid medication and disposal of leftover medication. The magnitude of opioid overprescribing was calculated using the reported prescribed and reported used number of opioid pills. Linear regression was used to examine associations between opioids and NSAIDs prescribed.

RESULTS

One hundred fourteen patients reported a mean prescription of 12.0 ± 5.0 pills, with utilization of 4.4 ± 6.1 pills over 2.7 ± 5.1 days. Patients were prescribed 2.73 times the number of opioid pills required on average. One hundred patients (87.7%) reported having unused opioid medication after their surgery, with 71 (71.0%) reporting opioid retention. Regression results showed an association with opioids used and prescribed opioid amount (β = 0.582, R = 0.471, P < 0.001).

DISCUSSION

Overall, our study results help characterize the utilization patterns of opioid medications in the postsurgical pediatric sports orthopaedic population and suggest that orthopaedic surgeons may be able to provide smaller quantities of opioid pills for analgesia than is typically prescribed, which in turn may help reduce the amount of prescription opioid medications present in the community.

LEVEL OF EVIDENCE

Level IV.

Characterizing the Effect of Perioperative Narcotic Consumption and Narcotic Prescription Dosing at Discharge on Satisfaction With Pain Control for Patients Undergoing Single-level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

A single-center, retrospective review of prospectively collected data on patients who underwent single-level anterior cervical discectomy and fusions (ACDFs) between October 2014 and October 2019.

OBJECTIVE

To investigate the effect of perioperative narcotic consumption and amount of narcotic prescribed at discharge on patient satisfaction with pain control after single-level ACDF.

SUMMARY OF BACKGROUND DATA

Prior research has demonstrated that opioid prescription habits may be related to physician desire to produce superior patient satisfaction with pain control.

METHODS

Patients with complete Press-Ganey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey information were analyzed. Inpatient opioid prescriptions were recorded and converted to milligram morphine equivalents (MME) and tablets of 5 mg oxycodone. HCAHPS scores were converted to a Likert-type 5-point scale.

RESULTS

A total of 47 patients met inclusion criteria for this study. Average age was 48.1±10.9 y. Average inpatient opioids prescribed was 102±106 MME. Average opioids prescribed at discharge was 437±342 MME. No statistically significant correlation was found between satisfaction with pain control and opioid consumption while in the hospital [r=-0.106, P=0.483]. Similarly, there was no statistically significant correlation between satisfaction with pain control and opioids prescribed upon discharge [r=-0.185, P=0.219]. No statistically significant correlation was found between date of surgery and inpatient MME consumption [r=-0.113, P=0.450]. Interestingly, more opioids were prescribed at discharge the earlier the date of surgery [r=-0.426, P=0.003]. For every additional month further along in the study period, the odds of a patient reporting a top box score for satisfaction with pain control increased by 5.5% [P=0.025].

CONCLUSION

Our study found no correlation between patient satisfaction with pain control and inpatient opioid dosage or outpatient prescription dosage after single-level ACDF. Moreover, satisfaction with pain control increased over time despite a decrease in MME prescribed at discharge. This suggests that factors other than narcotic consumption play a more important role in patient satisfaction with pain control.

LEVEL OF EVIDENCE

Level III.

Opioid Prescribing Risk Factors in Nonoperative Ankle Fractures: The Impact of a Prospective Clinical Decision Support Intervention

Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.

Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block

BACKGROUND

Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block.

METHODS

After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's R², scaled Brier score, and calibration slope.

RESULTS

The cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's R² 0.063, and scaled Brier score 0.047. Calibration slope was 0.832 (95% CI: 0.623-1.041).

CONCLUSIONS

We show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed.

CLINICAL TRIAL REGISTRATION

NCT05018104.

Clinical and Radiographic Outcomes of Percutaneous Chevron-Akin Osteotomies for the Correction of Hallux Valgus Deformity

BACKGROUND

Hallux valgus is a common cause of pain and dysfunction of the foot, sometimes requiring surgical correction when conservative measures fail. Although there are many methods of correction, one of the newer techniques is minimally invasive chevron-Akin (MICA). The aim of the current study is to evaluate clinical and radiographic effectiveness of MICA and narcotic use in a large patient cohort.

METHODS

All patients in this retrospective study were treated by a single fellowship-trained foot and ankle orthopaedic surgeon. Patient demographics were collected for all cases. Preoperative and postoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were measured in all patients on weightbearing 3-views radiographs. The Foot Function Index (FFI) was obtained pre- and postoperatively at each visit. All patients were prescribed regular use of ibuprofen for 3 days with acetaminophen and oxycodone reserved for breakthrough pain. Use of narcotic pain medication was recorded.

RESULTS

A total of 274 feet in 248 patients were included in the study. Overall, 87.9% were female and 12.1% were male. The mean preoperative IMA and HVA were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean FFI score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2.

CONCLUSION

MICA is good method to correct hallux valgus deformity with low postoperative narcotic use.

LEVEL OF EVIDENCE

Level III, restrospective cohort study of a single surgeon practice.

The potential for diversion of prescribed opioids among orthopaedic patients: Results of an anonymous patient survey

INTRODUCTION

Diversion of prescription opioid medication is a contributor to the opioid epidemic. Safe handling practices can reduce the risk of diversion. We aimed to understand: 1) if orthopaedic patients received instructions on how to safely handle opioids, 2) their typical storage/disposal practices, and 3) their willingness to participate in an opioid disposal program (ODP).

METHODS

Cross-sectional study of adult orthopaedic patients who completed an anonymous survey on current or past prescription opioid use, instruction on handling, storage and disposal practices, presence of children in the household, and willingness to participate in an ODP. Frequencies and percentages of responses were computed, both overall and stratified by possession of unused opioids.

RESULTS

569 respondents who reported either current or past prescription opioid use were analyzed. 44% reported receiving storage instructions and 56% reported receiving disposal instructions from a health care provider. Many respondents indicated unsafe handling practices: possessing unused opioids (34%), using unsafe storage methods (90%), and using unsafe disposal methods (34%). Respondents with unused opioids were less likely to report receiving handling instructions or using safe handling methods, and 47% of this group reported having minors or young adults in the household. Respondents who received storage and disposal instructions were more likely to report safe storage and disposal methods. Seventy-four percent of respondents reported that they would participate in an ODP.

CONCLUSION

While many orthopaedic patients report inadequate education on safe opioid handling and using unsafe handling practices, findings suggest targeted education is associated with better behaviours. However, patients are willing to safely dispose of unused medication if provided a convenient option. These findings suggest a need to address patient knowledge and behavior regarding opioid handling to reduce the risk of opioid diversion.

Patient-reported opioid analgesic use after discharge from surgical procedures: a systematic review

OBJECTIVE

This systematic review synthesizes evidence on patient-reported outpatient opioid analgesic use post-surgery.

METHODS

We searched Pubmed (February 2019), Web of Science and Embase (June 2019) for U.S. studies describing patient-reported outpatient opioid analgesic use. Two reviewers extracted data on opioid analgesic use, standardized use, and performed independent quality appraisals based on the Cochrane Risk of Bias Tool and an adapted Newcastle-Ottawa scale.

RESULTS

Ninety-six studies met eligibility criteria; 56 had sufficient information to standardize use in oxycodone 5 mg tablets. Patient-reported opioid analgesic use varied widely by procedure type; knee and hip arthroplasty had the highest postoperative opioid use, and use after many procedures was reported as < 5 tablets. In studies that examined excess tablets, 25%-98% of the total tablets prescribed were reported to be excess, with most studies reporting that 50%-70% of tablets went unused. Factors commonly associated with higher opioid analgesic use included preoperative opioid analgesic use, higher inpatient opioid analgesic use, higher postoperative pain scores, and chronic medical conditions, among others. Estimates also varied across studies due to heterogeneity in study design, including length of follow-up and inclusion/exclusion criteria.

CONCLUSION

Self-reported post-surgery outpatient opioid analgesic use varies widely both across procedures and within a given procedure type. Contributors to within-procedure variation included patient characteristics, prior opioid use, intraoperative and perioperative factors, and differences in timing of opioid use data collection. We provide recommendations to help minimize variation caused by study design factors and maximize interpretability of forthcoming studies for use in clinical guidelines and decision-making.

Opioid Prescribing Habits for Common Arthroscopic Procedures in Opioid Naïve Patients

Background:

With the opioid epidemic and the increasing number of opioid-related deaths, there is growing awareness in the medical community regarding the dangers of opioid overprescription. As a result, there is a willingness among physicians to abandon old norms and adopt new data-driven prescribing practices.

Purpose:

To demonstrate patient-reported consumption data of opioid medications after anterior cruciate ligament (ACL) reconstructions (ACLRs), knee arthroscopies, and rotator cuff repairs to provide data-driven guidelines for prescribing opioids after these procedures.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included in the study were 168 patients who underwent an ACLR, knee arthroscopy, or arthroscopic rotator cuff repair over a 17-month period. Patients were excluded if they had an opioid allergy, had preexisting opioid use, had an acute postoperative complication requiring further surgery, required hospitalization, exhibited drug-seeking behaviors, or were lost to follow-up. Medical records were reviewed to determine the number of opioid pills prescribed and the number of pills taken postoperatively. Prescribing was standardized in that 15 hydrocodone/acetaminophen pills (5/325 mg) were prescribed for all knee arthroscopy procedures and 40 hydrocodone/acetaminophen pills were prescribed for all ACL and rotator cuff procedures. The mean number of pills consumed and percentage of prescribed pills taken were analyzed in association with specific procedures and patient demographics.

Results:

Overall, the mean (±SD) reported opioid consumption overall was 13.5 ± 13.0 pills, with a utilization rate of 45.6% of the prescription. The mean reported opioid consumption for ACLRs, knee arthroscopies, and rotator cuff repairs was 19.1 ± 15.4, 7.2 ± 5.4, and 17.2 ± 14.3 pills, respectively (P < .001). This represented a utilization rate of 48%, 47%, and 41%, respectively.

Conclusion:

This study provides important information regarding opioid utilization after common arthroscopic procedures. For ACLRs, knee arthroscopies, and rotator cuff repairs, by respectively prescribing 20, 10, and 20 pills postoperatively, the amount of unused medications would decrease by 60%, 47%, and 64%, respectively. We recommend prescribing no more than 20, 10, and 20 hydrocodone/acetaminophen pills (5/325 mg) for ACLRs, knee arthroscopies, and arthroscopic rotator cuff repairs, respectively.

Postoperative Opioid Utilization and Patient Satisfaction in General Surgery Procedures: A Prospective Observational Study

BACKGROUND

Wide variation of opioid prescribing persists despite attempts to quantify number of opioids utilized postoperatively. We aim to prospectively determine number of opioids used after common surgery procedures to guide future prescribing.

METHODS

A prospective observational trial was performed of opioids prescribed and used postoperatively. Patients filled out pre- and postoperative surveys, and number of opioids utilized was captured at postoperative visit.

RESULTS

One-hundred-and-thirteen patients met inclusion. Median opioids prescribed exceeded number of opioids taken for all procedures. Median number of opioids taken postoperatively was fewer than 10 for all categories of procedures: simple skin/soft tissue 2 (IQR 1-4), complex skin/soft tissue 1.5 (IQR 0-14), simple laparoscopy 1 (IQR 0-20) and complex laparoscopy 4 (IQR 0-20), laparotomy 0 (IQR 0-26), and open inguinal hernia 2 (IQR 0-2). Nearly 80% of patients had leftover opioids, and 31% planned to keep them. There was little difference between preoperative and postoperative level of satisfaction with a pain control regimen.

DISCUSSION

Postoperatively, patients utilize opioids less frequently than prescribed and often keep leftover pills. Patient pain control satisfaction is unrelated to number of opioids prescribed and taken postoperatively.

Retrospective chart review of perioperative pain management of patients having surgery for closed ankle fractures using peripheral nerve blocks at a level one trauma center

Chronic opioid use is unfortunately perceived among these postoperative patients, specifically within orthopedic surgery. Patients having orthopedic surgeries are at risk for becoming addicted to opioids, and one benefit of peripheral nerves blocks could be to provide an alternative mode of pain control. This study takes a retrospective look at the use of peripheral nerve blocks for pain control following surgery for isolated traumatic ankle injuries. We hypothesize that when peripheral nerve blocks are administered preoperatively to patients with closed ankle fractures, they will have overall better control of postoperative pain compared to patients who did not receive a peripheral nerve block.

OBJECTIVES

The objective of this investigation was to evaluate the effect of preoperative peripheral nerve blockade on pain outcomes after ankle fracture surgery.

METHODS

After approval from our institutional review board, a Current Procedural Terminology code search was performed of all patients within our institution over a 3-year data collection period (August 2016-June 2019). This resulted in 177 subjects who underwent isolated closed ankle fracture open reduction internal fixation (ORIF), of which 71 subjects met inclusion criteria.

RESULTS

Results of the primary outcome measures found no difference in the mean postoperative care unit (PACU) pain scores between the groups (2.39 ± 2.91 vs 3.52 ± 3.09; P = 0.1724) nor the frequency of those who reported only mild pain (63.0% vs 47.10%; P = 0.2704). Subjects who received a peripheral nerve block spent more time in the PACU before discharge (2.06 ± 1.05 vs 0.94 ± 1.21 hours; P = 0.0004). Subjects receiving a peripheral nerve block were more likely to be given no analgesics in the PACU (38.9% vs 11.8%; P = 0.042) and less likely to receive a narcotic analgesic in the PACU (53.7% vs 82.4%; P = 0.047).

CONCLUSION

Although the results of this investigation demonstrate no significant difference in the mean PACU pain scores, they do demonstrate a significant difference in the amount of pain medication given in the PACU setting. This information will be used for future investigations of this discrepancy between pain perception and need for immediate postoperative pain medications as it relates to multimodal pain control in the setting of ankle fracture surgery.

Postoperative use of slow-release opioids: The impact of the Australian and New Zealand College of Anaesthetists/Faculty of Pain Medicine position statement on clinical practice

Dose titration with immediate-release opioids is currently recommended for acute pain. The Australian and New Zealand College of Anaesthetists and the Faculty of Pain Medicine released a statement in March 2018 supporting their use in the treatment of opioid-naïve patients; however, the impact of this statement on clinical practice is currently unknown. This retrospective cohort study was conducted to compare opioid prescribing patterns before and after the release of the recommendations. Data were collected on 184 patients (2017, n = 78; 2018, n = 106) admitted to the Prince of Wales Hospital in November 2017 and 2018, which consisted of demographic data, opioid prescriptions and discharge opioid information. The main outcome is the number of prescriptions of slow-release opioids in 2017 versus 2018 after the recommendations were published. Confounding factors were accounted for using logistic and multiple regression as appropriate. There was a 29% decrease in slow-release opioid prescriptions during hospitalisation ( n = 31, 40% versus n = 12, 11%; P < 0.001) and 17% decrease at discharge ( n = 20, 26% versus n = 9, 9%; P = 0.02) post-publication. After adjusting for confounders, the odds of slow-release opioids being prescribed postoperatively and at discharge reduced by 86% and 88%, respectively (postoperative period: odds ratio 0.14, P < 0.05; discharge: odds ratio 0.12, P < 0.05). In addition, orthopaedic patients were more likely to receive slow-release opioids, consistent with existing literature. As the use of slow-release opioids has been associated with increased harm and protracted opioid use compared to immediate-release opioids, it is hoped that wider dissemination of these recommendations and a change in prescribing practice can be a step towards overcoming the opioid crisis.

Predictors of mortality in inflammatory bowel disease patients treated for pneumonia

BACKGROUND

Community-acquired pneumonia is among the most common infections affecting ulcerative colitis and Crohn's disease patients. Data regarding epidemiology and outcomes of pneumonia in inflammatory bowel disease patients is lacking. We aimed to identify predictors of adverse outcomes among inflammatory bowel disease patients treated for pneumonia.

METHODS

This was a retrospective cohort study that included adult patients admitted to Sheba Medical Center for pneumonia between 2012 and 2018. Data was collected from an electronic repository of all emergency department admissions and included tabular demographic and clinical variables and free-text physician records. Pneumonia cases were extracted using the International Classification of Diseases (ICD-10) coding.

RESULTS

Of 16,732 admissions with pneumonia, 97 were inflammatory bowel disease patients (45 Crohn's disease; 52 ulcerative colitis). We found a similar rate of 30-day mortality among inflammatory bowel disease and non-inflammatory bowel disease patients (12.1% versus 11.3%, p = 0.824) and between Crohn's disease and ulcerative colitis patients (11.1% versus 11.5%, p = 0.947). There was an increased hospitalization rate among inflammatory bowel disease patients (92.8% versus 85.6%, p = 0.045), but similar hospitalization duration (4 versus 4 days, p = 0.384). Crohn's disease patients had a shorter hospitalization duration compared with ulcerative colitis patients (3 versus 5.5 days, p = 0.029). Bronchiectasis (adjusted odds ratio 60.95, 95% confidence interval 2.72-1364.39, p = 0.01) and opioids use (adjusted odds ratio 13.21, 95% confidence interval 1.29-135.18, p = 0.03) were associated with an increased 30-day mortality rate in inflammatory bowel disease patients.

CONCLUSION

This is the first study to identify predictors of mortality in inflammatory bowel disease patients with pneumonia. The rate of mortality and hospitalization duration of stay were similar among inflammatory bowel disease and non-inflammatory bowel disease patients. Use of opioids and presence of bronchiectasis were associated with a higher risk of mortality in inflammatory bowel disease patients with pneumonia.

Opioid Consumption and Time to Return to Work After Percutaneous Osteotomy in Foot Surgery

Surgeries involving the foot and ankle are painful procedures, with many patients unwilling to discontinue prescribed narcotics at 3 months postoperatively. Percutaneous techniques allow for smaller incisions and minimal soft tissue disruption. Fifty consecutive patients underwent outpatient percutaneous foot surgery. Data were collected on pain medication taken and time to return to work. A mean of 3.3 tablets of oxycodone were consumed during the first 2 weeks. No patient was taking narcotics after 2 weeks. Mean time to return to work was 18.9 days. Percutaneous foot and ankle surgery led to a significant reduction in narcotic consumption. [Orthopedics. 2020;43(4):e334-e337.].

Leftover opioids following adult surgical procedures: a systematic review and meta-analysis

BACKGROUND

US opioid prescribing and use escalated over the last two decades, with parallel increases in opioid misuse, opioid-related deaths, and concerns about diversion. Postoperatively prescribed opioids contribute to these problems. Policy makers have addressed this issue by limiting postoperative opioid prescribing. However, until recently, little data existed to guide prescribers on opioid needs postoperatively. This meta-analysis quantitatively integrated the growing literature regarding extent of opioids leftover after surgery and identified factors associated with leftover opioid proportions.

METHODS

We conducted a meta-analysis of observational studies quantifying postoperative opioid consumption in North American adults, and evaluated effect size moderators using robust variance estimation meta-regression. Medline, EMBASE, Cumulative Index of Nursing and Allied Health Literature, and Cochrane Database of Systematic Reviews were searched for relevant articles published January 1, 2000 to November 10, 2018. The Methodological Index for Non-Randomized Studies (MINORS) tool assessed risk of study bias. The proportion effect size quantified the primary outcome: proportion of prescribed postoperative opioids leftover at the time of follow-up. Primary meta-regression analyses tested surgical type, amount of opioids prescribed, and study publication year as possible moderators. Secondary meta-regression models included surgical invasiveness, age, race, gender, postoperative day of data collection, and preoperative opioid use.

RESULTS

We screened 911 citations and included 44 studies (13,068 patients). The mean weighted effect size for proportion of postoperative opioid prescriptions leftover was 61% (95% CI, 56-67%). Meta-regression models revealed type of surgical procedure and level of invasiveness had a statistically significant effect on proportion of opioids leftover. Proportion of opioids leftover was greater for "other soft tissue" surgeries than abdominal/pelvic surgeries, but did not differ significantly between orthopedic and abdominal/pelvic surgeries. Minimally invasive compared to open surgeries resulted in a greater proportion of opioids leftover. Limitations include predominance of studies from academic settings, inconsistent reporting of confounders, and a possible publication bias toward studies reporting smaller leftover opioid proportions.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

A significant proportion of opioids are leftover postoperatively. Surgery type and level of invasiveness affect postoperative opioid consumption. Integration of such factors into prescribing guidelines may help minimize opioid overprescribing while adequately meeting analgesic needs.

Prolonged Opioid Use After Surgery for Early-Stage Breast Cancer

INTRODUCTION

This study examined the patterns of prolonged opioid use and the factors associated with higher risk of prolonged opioid use among opioid-naïve working-age patients with early-stage breast cancer.

METHODS

Using MarketScan data, the study identified 23,440 opioid-naïve patients who received surgery for breast cancer between January 2000 and December 2014 and filled at least one opioid prescription attributable to surgery. Prolonged opioid use was defined as one or more prescriptions for opioids within 90 to 180 days after surgery and defined extra-prolonged opioid use as one or more opioid prescriptions between 181 and 365 days after surgery. Multivariable logistic regressions were performed to ascertain factors associated with prolonged and extra-prolonged use of opioids.

FINDINGS

Of the 23,440 patients, 4,233 (18%) had prolonged opioid use, and 2,052 (9%) had extra-prolonged opioid use. Patients who received mastectomy plus reconstruction had the highest rate of prolonged opioid use (38%) followed by mastectomy alone (15%). A multivariable logistic regression confirmed that patients with mastectomy and reconstruction had the highest odds ratio of prolonged opioid use compared to lumpectomy and whole breast irradiation (adjusted odds ratio, 5.6; 95% confidence interval, 5.1-6.1). Mean daily opioid dose was consistently high without any obvious dosage reduction among patients with opioid use.

INTERPRETATION

This large observational study showed a high rate of prolonged opioid use among patients who received surgery for early-stage breast cancer and found significant difference in prolonged opioid use by treatment type.

IMPLICATIONS FOR PRACTICE

This large observational study found a high rate of prolonged opioid use among working-age patients with early-stage breast cancer who received curative surgery, especially among patients who received mastectomy. Among patients with opioid use, the mean daily opioid dose was consistently high without any obvious dosage tapering. This study highlights the need to emphasize appropriate opioid therapy and potential dosage reduction or discontinuation among patients with early-stage breast cancer who received surgical interventions.

Opioid Use After Common Sports Medicine Procedures: A Systematic Review

CONTEXT

The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America.

OBJECTIVE

To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures.

DATA SOURCES

A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018.

STUDY SELECTION

Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies.

RESULTS

A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill.

CONCLUSION

Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.

Association of Preoperative Opioid Use and Prolonged Postoperative Opioid Use Following Total Ankle Arthroplasty

Background:

Perioperative opioid consumption has received a great deal of recent attention. However, perioperative opioid utilization in the total ankle arthroplasty (TAA) population has not been well studied. We sought to identify factors associated with postoperative opioid use following TAA.

Methods:

The PearlDiver Research Program was used to query the Humana, Inc, administrative claims database from 2007 to 2017 for patients undergoing TAA. Additional variables of interest were identified using ICD-9 and ICD-10 codes. Preoperative opioid use was defined as having filled an opioid prescription in the 3 months before TAA. Prescription opioid claims data were tracked for 12 months postoperatively. Risk ratios (RRs) were calculated and multivariate analysis was performed at 3, 6, and 12 months postoperatively.

Results:

A total of 544 patients who underwent TAA were identified, with 180 (33.1%) filling an opioid prescription preoperatively. Those filling prescriptions preoperatively had a significantly greater risk for postoperative opioid use compared to those not taking opioids (RR: 4.36 [95% confidence interval (CI): 2.80-6.80] at 12 months). Anxiety or depression (RR: 2.27 [1.44-3.59]), low back pain (LBP) (RR: 2.27 [1.50-3.42]), and fibromyalgia (RR: 2.15 [1.42-3.28]) were also found to increase the risk of taking opioids at 12 months postoperatively. Multivariate analysis found preoperative opioid use to be the strongest predictor of postoperative opioid use.

Conclusions:

Nearly one-third of patients filled an opioid prescription within 3 months of TAA, and filling a prescription preoperatively was the strongest factor associated with postoperative opioid use. Fibromyalgia, depression or anxiety, and LBP were also associated with an increased likelihood of postoperative opioid use.

Level of Evidence:

Level III, retrospective cohort study.

Prospective Evaluation of Opioid Use After Adoption of a Prescribing Guideline for Outpatient Foot and Ankle Surgery

BACKGROUND

In 2016, our provider group adopted an initial prescription opioid maximum guideline to reduce overprescription of opioids. The purpose of this study was to prospectively assess opioid consumption patterns following implementation of this guideline in patients undergoing outpatient foot and ankle surgery.

METHODS

Over a 1-year period, we prospectively analyzed opioid prescription and use patterns of 303 consecutive patients. Opioid consumption was verified by pill counts completed at the 2- and 6-week postoperative visits. The morphine equivalent dose was calculated for each prescription and converted to the equivalent 5-mg oxycodone "pill." We used the regression coefficients from a regression model of opioid consumption to create a revised guideline for maximum initial opioid prescriptions based on patient age, bony vs nonbony procedure, and anatomic location (forefoot/midfoot/hindfoot/ankle).

RESULTS

On average, 37.4 pills were prescribed and 18.9 pills used (47.6% utilization). Only 17.2% of patients used their full prescription quantity. By 2 weeks, 88% of patients no longer used opioids. Only 1.3% of patients used prescription opioids beyond 6 weeks. Independent risk factors for increased opioid consumption were younger age (P = .003), male sex (P = .007), recent preoperative opioid use (P = .019), bony procedures (P < .001), and ankle/hindfoot procedures (P = .016 and P < .001).

CONCLUSION

This study showed the amount of opioid consumption for patients undergoing foot and ankle procedures. We present a modified guideline for the maximum initial prescription of opioids following outpatient foot and ankle procedures that can be used as a benchmark for further study in decreasing overprescribing.

LEVEL OF EVIDENCE

Level II, prospective observational cohort study.

Postoperative Opioid Consumption in Opioid-Naïve Patients Undergoing Hallux Valgus Correction

BACKGROUND

Postoperative pain management following orthopedic surgeries can be challenging, and the opioid epidemic has made it essential to better individualize opioid prescriptions by patient and procedure. The purpose of this subgroup analysis of a prospective study was to investigate immediate postoperative opioid pill consumption and prolonged use in patients undergoing operative correction of hallux valgus (HV).

METHODS

Patients undergoing outpatient HV correction procedures with 5 fellowship-trained foot and ankle surgeons over a 1-year period were included. Patients were excluded if they were being prescribed chronic opioid analgesics for an underlying condition prior to the date of initial injury or if they underwent concomitant nonforefoot procedures. At the patient's first postoperative visit, opioid pills were counted, and these were standardized to the equivalent number of 5-mg oxycodone pills. Linear regression analysis was performed to determine if any of the procedure categories or patient factors were independently associated with postoperative opioid consumption. Prolonged use of opioids 90 to 180 days after the procedure was also examined using our state's online Prescription Drug Monitoring Program (PDMP). One-hundred thirty-seven patients (86% female) were included. Thirty-six patients (26%) underwent primary chevron osteotomies, 78 (57%) underwent primary proximal osteotomies (Ludloff, scarf), 10 (7%) underwent soft tissue-only procedures with or without a first proximal phalanx osteotomy (modified McBride, Akin), and 13 (9%) underwent first metatarsophalangeal arthrodeses.

RESULTS

Overall, patients consumed a median of 27 pills. There was no significant difference in postoperative opioid intake between the 4 procedures, including when subdivided into those with and without lesser toe procedures. Higher preoperative visual analog scale pain levels (P = .028) and younger patient age (P = .042) were associated with higher opioid pill consumption. A total of 1.5% of patients demonstrated prolonged opioid use.

CONCLUSION

Our study demonstrated a lack of difference between HV procedures in terms of postoperative opioid consumption and an overall low rate of prolonged use in opioid-naïve patients.

LEVEL OF EVIDENCE

Level III, comparative study.

Postdischarge Opiate-Prescribing Habits for Primary THA and TKA: A Survey of American Association of Hip and Knee Surgeons Members

Abuse of opiate medications has reached epidemic proportions, and elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) typically require outpatient use of narcotic medications. This survey sought to determine opiate-prescribing habits of members of the American Association of Hip and Knee Surgeons (AAHKS) for patients undergoing primary THA and TKA. An 11-question online survey was developed to evaluate current prescribing habits for opiate and nonopiate medications prescribed after primary THA and TKA. An invitation to complete the survey was e-mailed to 2698 orthopedic surgeons using an AAHKS listserv. Surgeons' demographic information and their prescribing habits of opiate and nonopiate medications postdischarge were recorded. Data were examined using descriptive statistics, chi-square, and multivariate logistic regression. Responses were received from 325 of 2698 (12.1%) AAHKS members. Significant variation in the type of opiate prescribed and the number of pills dispensed was observed. Higher surgical volume and less years in surgical practice were associated with a higher number of opiate pills prescribed after THA and TKA. There were no statistically significant associations between opiates prescribed and use of an ambulatory surgery center or presence of departmental guidelines. Although THA and TKA are relatively standardized procedures performed nationwide, significant variability exists among surgeons regarding postdischarge opiate- and nonopiate-prescribing habits. There is a need for greater standardization to create a unified, evidence-based, and safe regimen for the postoperative period while reducing the opiate burden in the surrounding community. [Orthopedics. 2019; 42(6):361-367.].

Effect of the Strengthening Opioid Misuse Prevention (STOP) Act on Opioid Prescription Practices After Ankle Fracture Fixation

Background:

In North Carolina, the Strengthen Opioid Misuse Prevention Act of 2017 (STOP Act) went into effect on January 1, 2018, intending to increase oversight over opioid prescriptions. This study compares postoperative narcotic prescription practices following operative fixation of ankle fractures before and after the STOP Act.

Methods:

This study was a retrospective review of patients 18 years and older who underwent operative fixation of ankle fractures between January 1 and June 30, 2017 (before STOP Act), and between January 1 and June 30, 2018 (after STOP Act). Variables of interest included demographics, amount of opioids prescribed postoperatively, number of prescription refills, and number of pain-related calls or visits to the emergency department (ED) or clinic after surgery. This study assessed 71 patients in the Pre group and 47 patients in the Post group.

Results:

There was a statistically significant decrease in the average number of postoperative narcotic pills prescribed after the STOP Act (52.7 vs 76.2, P < .001). There was also a statistically significant decrease in the average number of prescription refills (0.6 vs 1.0, P = .037). There were no significant changes in pain-related clinic calls (35.2% Pre vs 34.0% Post, P = .896), pain-related clinic visits ahead of schedule (4.2% Pre vs 6.4% Post, P = .681), or pain-related ED visits (2.8% Pre vs 10.6% Post, P = .113).

Conclusion:

In the postoperative period after operative fixation of ankle fractures, the volume of narcotic prescriptions decreased after the new legislation, without an associated strain on medical resources.

Level of Evidence:

Level III, therapeutic, comparative study.

Opioid Crisis and Acute Pain Management After Foot and Ankle Surgery

Opioid abuse has plagued the United States, with a resurgence since the early 2000s. Governmental agencies, pharmaceutical companies, patients, and physicians have all contributed to this crisis. Severe pain has been reported following foot and ankle surgery. There are current national guidelines for chronic opioid prescribing, but guidelines for acute pain have not been established. Prescribing fewer opioids, education on opioid risks, proper disposal of unused medication, and participating in prescription monitoring programs help reduce opioid abuse. Multimodal analgesia is paramount in managing pain while reducing opioid consumption after postoperative foot and ankle surgery.

Opioid Consumption Rate Following Foot and Ankle Surgery

BACKGROUND

The rapid increase in the consumption of prescription opioids has become one of the leading medical, economic, and sociological burdens in North America. In the United States, orthopedic surgery is the fourth leading specialty in the number of opioids prescribed, and the largest among all operative specialties. There is insufficient evidence to guide surgeons about appropriate opioid prescription amounts after orthopedic foot and ankle (F&A) procedures. The aim of this study was to determine the opioid consumption rate after foot and ankle procedures and identify risk factors associated with higher use.

METHODS

A total of 535 patients who underwent foot and/or ankle surgery between August 2016 and March 2018 were included in the study. Each patient received a preoperative discussion about postoperative pain and expectations alongside a standardized handout. At the 2-week postoperative visit, the patients self-reported the amount of consumed opioids. Prescription details, number of opioid pills consumed, refill requests, pain-issue-related telephone calls, and additional physician/emergency department visits were documented. Patient demographics, comorbidities, use of regional anesthesia, hospitalization, surgery type/severity, and preoperative opioid use were collected. A total of 244 patients had a sufficiently complete data set for inclusion in the final cohort. Subjects had a mean age of 50 years (±16.3) and a body mass index (BMI) of 29 (±6.1). Sixty-six (27%) patients underwent a soft tissue procedure alone and 178 (73%) underwent a bony procedure.

RESULTS

On average, patients consumed 46.6% of the prescribed pills following a bony procedure and 42.4% after a soft tissue procedure, which resulted in a total of 4496 leftover pills. BMI, procedure type (bony vs soft tissue)/severity, and number of opioids prescribed were positively correlated with elevated consumption rates (P = .008, P < .001, P < .001, P < .001, respectively).

CONCLUSION

BMI, procedure type, and higher initial pill dispensation correlated with a larger number of consumed pills during the postoperative period. On average, patients took 42.4% of the prescribed opioid after soft tissue procedures and 46.6% after bony procedures, resulting in a significant number of unused pills. Future guidelines are necessary to improve postoperative pain management to prevent narcotic overprescription and minimize the downstream potential for unprescribed community opioid access.

LEVEL OF EVIDENCE

Level III, retrospective case series, analytic.

Ultrasound-guided ankle block. History revisited

Following forefoot surgery, compared to the traditional multimodal approach, regional anesthesia and analgesia provides high quality pain relief, decreases opioids consumption and leads to very high satisfaction scores. Traditional regional techniques relied either on wound infiltration, landmark technique ankle blocks or popliteal sciatic nerve block. Numerous anatomic variations of the different nerves might lead to failure following a blind technique. The current evolution towards ambulatory care will push surgical teams to favor techniques that simplify postoperative treatment and encourages immediate ambulation. The development of Ultrasound Guided Blocks has enabled us to perform very selective and precise nerve blocks. Ankle blocks provide excellent intraoperative anesthesia as well as long postoperative pain relief. Complications are rare using regional anesthesia for postoperative analgesia even after extensive foot surgery. Revival of ankle blocks is a perfect example of the high impact of new technological advances in improving ambulatory surgical care after foot surgery.

Benchmarks of Duration and Magnitude of Opioid Consumption After Total Hip and Knee Arthroplasty: A Database Analysis of 69,368 Patients

BACKGROUND

Opioid prescribing after orthopedic surgeries varies widely, and there is little consensus establishing proper standards of care. This retrospective cohort study examines opioid prescribing trends following total hip (THA) and knee (TKA) arthroplasty and evaluates preoperative opioid use as a predictor of duration and magnitude of postoperative opioid use.

METHODS

Patients who underwent THA or TKA in a nationwide insurance database were stratified by preoperative opioid use. Naive, sporadic, and chronic users were defined as 0, 1, or 2+ prescriptions filled 6 months before surgery. Patients were excluded for readmission or subsequent surgery. Duration of opioid use was defined as time between the procedure and the last opioid prescription record, and magnitude of opioid use was defined as quantity of pills filled by 30 days postop.

RESULTS

Naive patients were less likely than chronic users to fill any opioid prescription after surgery (THA: 61.5% naive vs 90.4% chronic, TKA: 72.0% naive vs 95.9% chronic), and they obtained fewer pills (THA: 73 pills naive vs 126 pills chronic, TKA: 86 pills naive vs 126 pills chronic, 5-mg oxycodone equivalent). Between 10% (THA) and 13% (TKA) of naive and between 47% (THA) and 62% (TKA) of chronic users continued opioid use at 1 year postop.

CONCLUSION

Chronic users obtain more opioids postoperatively and continue filling prescriptions for longer than naive patients. This work benchmarks norms regarding opioid use and furthermore these data highlight the powerful effect of opioid exposure during surgery as 10%-13% of naive patients continued opioids at 1 year postop.

Prospective Evaluation of Utilization Patterns and Prescribing Guidelines of Opioid Consumption Following Orthopedic Foot and Ankle Surgery

BACKGROUND

Overprescription of narcotic pain medication is a major culprit in the present opioid epidemic plaguing the United States. The current literature on lower extremity opioid usage has limitations and would benefit from additional study. The purpose of our study was to prospectively assess opioid consumption patterns following outpatient orthopedic foot and ankle procedures.

METHODS

Patients undergoing outpatient orthopedic foot and ankle procedures who met inclusion criteria had the following prospective information collected: patient demographics, preoperative health history, patient-reported outcomes, anesthesia type, procedure type, opioid prescription and consumption details. The morphine equivalent dose was calculated for each prescription and then converted to the equivalent of a 5-mg oxycodone "pill." Univariable analyses were performed to identify variables with a statistically robust association with opioid consumption for inclusion in a multivariable linear regression. A stepwise backward regression was then performed to identify independent predictors of opioid consumption. Postoperative opioid utilization was reported for 988 patients (mean age: 49 years).

RESULTS

Overall, patients consumed a median of 20 pills whereas the median number of pills prescribed was 40. This resulted in a utilization rate of 50% and 20 631 pills left unused. Independent factors associated with higher opioid consumption were anesthesia type ( P < .004), age <60 years ( P < .001), preoperative visual analog scale (VAS) pain report of >6 ( P = .008), and bony procedures ( P = .008); residual standard error 16.73 ( F_7,844=14.3, P < .001).

CONCLUSION

Our study found that patients who underwent orthopedic foot and ankle procedures were overprescribed narcotic medication by nearly twice the amount that was actually consumed. Although we identified 4 independent factors associated with opioid consumption, the large residual standard error suggests that there remains a substantial degree of unexplained variance of opioid consumption observed in the patient population. Physicians face a challenging task of setting appropriate protocols when balancing pain relief and generalizable guidelines.

LEVEL OF EVIDENCE

Level II, prospective observational cohort study.