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by Brian McCurdy, Managing Editor for Podiatry TodayLink to original article

Foot and ankle surgeons prescribe post-op opioids at a rate twice as high as patients consume them, according to a recent study.

The study, published in Foot and Ankle International, reviewed the opioid usage by 988 patients who had outpatient orthopedic foot and ankle surgeries. The researchers note patients took a median of 20 opioid pills when the median number of prescribed pills was 40. The study identified four independent factors associated with the consumption of opioids: anesthesia type, age below 60 years, preoperative Visual Analog Scale (VAS) pain report of more than 6 and bony procedures. However, the authors add that there is a “substantial degree of unexplained variance” in prescription opioid use.

Troy Boffeli, DPM, historically has prescribed 40 tablets of opioid medication postoperatively but found patients only took about half this amount. He notes this led to a new protocol about one year ago in which he and his colleagues began prescribing 20 tablets.

“There was concern that this change would result in more phone calls and refills, but that was not our experience,” says Dr. Boffeli, who is in private practice at HealthPartners Specialty Center in St. Paul, MN. “Part of the protocol was to educate patients about what to do with leftover pills so that they do not become misused.”

Noting that he is not a surgeon, Robert Smith, DPM, MSc, RPh, CPed, CPRS, has rarely prescribed opioids and always limits the amount to a maximum or three days only. He will refer patients to chronic pain management if his treatment selection and medical pharmaceutical intervention did not meet the patient’s expectation. On those few occasions patients do take opioids, he refers patients to a pharmacy with a locked metal box for controlled substances or provides information centered on drug take-back programs that allow people with unused medications to bring them in for proper disposal.

Podiatric physicians are not overprescribing opioids, asserts Dr. Smith, who is in private practice at Shoe String Podiatry in Ormond Beach, FL. He cites a recent Podiatry Management survey of 1,039 podiatrists, who noted prescribing opioids at an equal to lower rate in comparison to their overall weekly prescriptions.

Dr. Smith believes both federal and state opioid prescribing regulations greatly impact how specialty physicians prescribe opioids. He cites the use of an national evidence-based approach to pain education, including pharmacologic and nonpharmacologic treatments, and materials on opioid prescribing as well as prescription drug monitoring programs to help address the opioid epidemic by allowing prescribers and other stakeholders to track prescribing and dispensing information.  

To prescribe opioids more effectively, Dr. Smith advises assessing the potential risks of opioids before prescribing, using treatment agreements with patients and using urine toxicology screens.

To control pain without overprescribing narcotics, Dr. Boffeli advises screening for high-risk patients (checking for past narcotic use or abuse, anxiety, addiction), educating patients about what to expect, and explaining why it is not a good idea to be on narcotics for weeks. He also advises developing a multimodal pain management regimen including scheduled acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) for primary pain control with reserved use of narcotic medications for breakthrough pain.

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