CORR Insights®: Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review

Where Are We Now? Orthopaedic surgeons have drastically changed their prescribing habits. Multimodal pain pathways are now the norm, and patients are more knowledgeable about the dangers associated with opioid use. In my practice, I have noticed increasing patient concern about postoperative narcotic prescriptions. Some patients manage with no narcotics at all by their own requests. Still, the opioid epidemic persists. In the United States, opioid use continues to increase [2, 4], and the rate of overdose deaths is rising [8]. As orthopaedic surgeons, it is tempting to lay the blame elsewhere. Our solutions to pain are often interventional; we send patients for physical therapy, give injections, and discuss ways to reduce inflammation. When pain persists, we depend on surgical solutions rather than long-term pain management. But orthopaedic surgeons prescribe opioids more than practitioners of nearly any other medical discipline do; we rank third among all specialties [11]. Furthermore, about 9% of opioid-naïve orthopaedic patients continue to use opioid medications for longer than 2 months after foot and ankle surgery [3]. We are a part of the problem. In an article in this month’s Clinical Orthopaedics and Related Research®, Badin et al. [1] synthesized current data in a systematic review evaluating opioid use in the setting of foot and ankle trauma surgery. Their findings emphasize the problem: Up to 18% of patients who were opioid-naïve before surgery continue to use opioids persistently after surgery; the percentage is even higher in patients with prior opioid exposure. Studies evaluating alternative pain management strategies showed reduced opioid use after surgery. The authors therefore recommended a multimodal approach including regional anesthesia and limiting opioid prescriptions to 1 week after surgery. Based on these discoveries, surgeons should take the time to discuss nonpharmacologic strategies to reduce pain after lower extremity surgery like proper elevation techniques and frequent ice application to the popliteal fossa. Short-duration NSAID use substantially reduces pain and does not seem to affect bony healing. In patients with normal renal function, 30 mg of ketorolac can be given intraoperatively, followed by a 5-day course of 10 mg of ketorolac orally every 6 hours. Furthermore, single-shot popliteal and saphenous peripheral nerve blocks with 0.5% ropivacaine provide excellent postoperative pain relief with a low risk of adverse events. The opioid requirement is minimal while regional anesthesia is in effect, and if patients are told to anticipate a pain spike as the nerve block wears off, then they can usually manage it well and wean off the narcotics within a few days. Where Do We Need To Go? The number of studies assessing opioid prescribing practices and use after orthopaedic surgery continues to increase. There is a general understanding of how to reduce postoperative opioid prescriptions, and many of the principles of reducing postoperative pain can be applied in the setting of foot and ankle surgery. But researchers have failed to make specific and concrete recommendations. A patient’s pain level after foot and ankle surgery depends on a seemingly infinite number of variables such as bony versus soft tissue, elective versus trauma-related surgery, surgery duration, type of postoperative immobilization, medical comorbidities, and prior opioid exposure. Although many factors may be controlled for in well-designed studies, there is still the variable of how patients experience pain. For example, some patients who present with acute Achilles rupture are nearly pain free, able to bear weight, and have minimal pain during a Thompson test or palpation of the rupture site. Others present with substantial pain and are unable to bear weight or tolerate physical examination maneuvers. These patients usually have nearly identical demographic variables, injury type, and rupture mechanism, yet their experience of pain is vastly different. This highlights how difficult it is to study pain levels and pain management after foot and ankle surgery, no matter how tightly the variables are controlled in the study groups. Future studies might therefore explore the less tangible factors that affect pain levels after surgery. With an improved knowledge of factors that predict pain levels after surgery, a pain prediction scale can be developed and validated to identify patients who might be at the highest risk of having prolonged opioid use after surgery. Individual studies will always have limitations, but trends are emerging as the body of research grows. For example, three recent prospective studies identified that patients consumed fewer than half of the total number of pills given after surgery [5, 6, 10]. Are we overprescribing, or are patients budgeting their pills based on the total quantity they are prescribed? This question is difficult to answer, but we must persist. How Do We Get There? Pain is subjective, and defining a subjective quality in objective terms is not an easy task. Opioid requirements after surgery can be prospectively correlated with the results of the validated Pain Catastrophizing Scale in a homogenous group, such as patients undergoing Achilles tendon rupture repair or first metatarsophalangeal joint arthrodesis. Assessing anxiety levels at the time of surgery and opioid use may also reveal factors predisposing patients to greater opioid requirements. Once additional risk factors are defined, a brief preoperative questionnaire can be developed and validated to help predict whether patients will require negligible, moderate, or substantial narcotic prescriptions for their perioperative pain to be adequately controlled. The best way to accurately assess opioid use after foot and ankle procedures is with prospective studies that define the actual consumption of prescribed medication by counting pills prescribed and pills consumed. NSAID use after lower extremity surgery seems to be safe in terms of bony healing [7], but many surgeons are still reluctant to routinely recommend their use. Further exploring the safety of NSAIDs regarding their potential negative effects on bone healing with larger studies would be beneficial to routinely incorporate these drugs into the multimodal pain pathway. For example, this could be studied retrospectively by comparing union rates after ankle arthrodesis or triple arthrodesis results by a single surgeon or group before and after implementing a multimodal pain approach that includes NSAIDs. Finally, patient education avenues should be explored. Preoperative counseling has been shown to reduce opioid consumption after lower extremity surgery [9]. Reviewing a patient handout or presenting a short video to a patient preparing for surgery would be easy avenues to educate patients about the utility and dangers of opioid pain medications. Patients tolerate the postoperative period better when the surgeon sets clear expectations. Understanding and reducing opioid use after surgery is not an easy task, but our role in the opioid epidemic persists, and our work as orthopaedic surgeons is still not done.