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After Foot and Ankle Surgery, Patients Consume Less than Half the Opioid Prescribed

Key findings

  • In a retrospective study of 525 patients who had foot and ankle surgery performed by the same surgeon, the average number of opioid pills consumed postoperatively was less than half of the number initially prescribed
  • The excess amounted to 4,496 leftover oxycodone 5 mg pills, considered at risk for diversion into the community
  • The correlation between prescription and opioid consumption level was not affected by the severity of the procedure
  • Prior chronic use of opioids was not a risk factor for greater use of opioids

According to several recent studies, orthopedic surgeons prescribe more opioids than any other surgical specialists—accounting for 8% of total prescriptions. Recent research also shows that greater opioid use correlates with longer hospital stays, lower patient satisfaction, reduced functional outcome and increased morbidity.

To better understand appropriate prescription amounts, Christopher DiGiovanni, MD, chief of the Foot and Ankle Center, and colleagues in the Massachusetts General Hospital Department of Orthopaedics, studied 244 patients who had a foot and ankle procedure performed by a single surgeon between August 2016 and March 2018.

The study group's findings, reported in Foot & Ankle International, confirm findings of at least a few other related investigations: the number of dispensed opioid pills given by providers tends to be at least twice as high as what patients actually required. The more pills that get prescribed, the more pills that get used, and vice versa—suggesting that preoperative patient education and expectation play an important role in recovery and overall opioid consumption.

Pain Control Protocol

Most patients received a peripheral nerve block in the preoperative holding area. In the recovery room, the nursing staff told patients to start taking pain medication as soon as they felt pain/tingling in the affected foot or ankle.

Four types of oral opioids were prescribed: oxycodone 5 mg, hydrocodone–acetaminophen 5 to 325 mg, hydromorphone 2 mg and tramadol 50 mg. For purposes of the study, opioid consumption rates were converted into morphine milligram equivalents, then reconverted into oxycodone 5 mg pills to standardize the opioid amount.

Pills Prescribed vs. Consumed

  • All patients received an opioid prescription at discharge, and the average number of pills dispensed (oxycodone 5 mg equivalent) was 33.9
  • Patients consumed an average of 15.5 pills
  • Overall, only 46% of the initial prescription was consumed, leaving 4,497 leftover pills that could have been diverted into the community for potential abuse
  • On average, patients took 42% of the prescribed opioid after soft tissue procedures and 47% after bony procedures

Refill Requests

Eleven patients made refill requests, and 10 filled them. In the other case, the patient decided to continue with only nonsteroidal anti-inflammatory medication.

The 10 patients received an average of 17 additional pills, amounting to 57% of the initially prescribed opioid amount. Four of the 10 patients were prescribed lower-strength medications for the refill in an effort to wean them off rapidly.

Consumption-related Risk Factors

  • More pills prescribed initially, more pills consumed. This was found to be true regardless of procedure type/severity
  • The percentage of pills consumed did not necessarily increase with greater severity of the procedure. In absolute terms, therefore, there were more leftover pills after a major procedure than after more minor ones
  • Body mass index (BMI) was positively correlated with opioid consumption
  • Prior chronic use of opioids was not found to be a risk factor for greater use of postoperatively prescribed opioids
  • On multivariable regression analysis, both the absolute number of pills prescribed initially as well as the BMI remained independently associated with consumption levels

Suggestions for Surgeons

If surgeons continue to decrease the number of pills prescribed, it is extremely likely that patients will continue to consume fewer pills postoperatively—regardless of the nature of their procedure

  • Pre-operative patient education and the setting of expectations regarding postoperative pain control and opioid use are important parameters for improving patient satisfaction and reducing opioid consumption
  • Consider not giving refills unless a patient reports an adverse reaction to the original opioid. All authors adopted this practice after the completion of this study, and have since found it to be an overwhelmingly successful policy
  • Patients who receive a peripheral block should actually be expected to have less postoperative pain in the acute post-operative setting and should, therefore, be prescribed (and be expected to need to consume) fewer pain pills
  • Do not assume that patients with higher BMIs need a greater amount of opioids. BMI >30 can actually increase the half-lives of opioids, leading to accumulation and related side effects
  • Be aware that prior use of an opioid is a risk factor for prolonged and greater opioid demand postoperatively
    • Have an open discussion with any patient who is on chronic opioid therapy or has a history of substance use. Outline clear expectations about prescribing policy and opioid use. Make it clear that the only opioids provided in this setting will be the routine amounts given for these procedures and that any amounts required beyond these amounts should come from the prior pain control prescriber (who should also be made aware of the upcoming surgery and potential for a transient increase in pain medication requirements)
    • Collaborate with the patient's other health care professionals to devise the safest and most effective postoperative pain regimen

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