Mitigating the Shadow of the Worldwide Opioid Crisis: A Review for the Foot and Ankle Specialist

2019 ◽  
Vol 13 (3) ◽  
pp. 242-248
Author(s):  
Robert G. Smith
Keyword(s):  
Pain Management ◽  
Lower Extremity ◽  
Pain Therapy ◽  
Opioid Analgesics ◽  
The United States ◽  
Opioid Therapy ◽  
Foot And Ankle ◽  
Conflicting Information ◽  
Free Environment

The foot and ankle physician is no stranger to the difficulties in achieving optimal pain therapy. There remains much confusion and conflicting information available to nonspecialist prescribers regarding opioid therapy as well as great deal of fear or opiophobia during the prescribing and monitoring of opioids worldwide. The role of the lower extremity specialist provider is to responsibly provide pain management to their patients in an error-free environment. The purpose of this article is to explore the central theme of responsible opioid pain management worldwide. This review focuses on the prescribing strategies of opioid analgesics to treat lower-extremity pain. Pharmacology of opioid agents and opioid prescribing strategies will be presented. Then, the concept of multimodal pain relief criteria for selecting appropriate opioid analgesics and use of adjunctive therapies to prevent opioid misuse as presented in the current medical literature is reported. Finally, a commentary and discussion centered on the actions of pharmaceutical companies of promoting their opioid products and the negative outcomes of their actions in the United States that may go worldwide if behaviors of these companies are not recognized by the foot and ankle specialist.

scholarly journals The Role of Opioid Analgesics in Geriatric Pain Management

2016 ◽  
Vol 32 (4) ◽  
pp. 725-735 ◽  
Author(s):  
Jennifer Greene Naples ◽  
Walid F. Gellad ◽  
Joseph T. Hanlon
Keyword(s):  
Pain Management ◽  
Opioid Analgesics ◽  
Geriatric Pain

(140) The role of tapentadol ER in the illicit market for opioid analgesics in the United States

2014 ◽  
Vol 15 (4) ◽  
pp. S11
Author(s):  
C. Le Lait ◽  
G. Severtson ◽  
H. Surratt ◽  
J. Burke ◽  
V. Bebarta ◽  
...  
Keyword(s):  
United States ◽  
Opioid Analgesics ◽  
The United States ◽  
Illicit Market

scholarly journals Pain Management after Outpatient Foot and Ankle Surgery

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0003
Author(s):  
Austin Sanders ◽  
Akash Gupta ◽  
Mackenzie Jones ◽  
Matthew Roberts ◽  
David Levine ◽  
...  
Keyword(s):  
Pain Management ◽  
Peripheral Nerve ◽  
Pain Control ◽  
Outpatient Surgery ◽  
The United States ◽  
Prescribing Patterns ◽  
Foot And Ankle ◽  
Nerve Blocks ◽  
Ankle Surgery ◽  
Long Acting

Category: Pain Management, Anesthetic Advances Introduction/Purpose: The number of opioid prescriptions in the United States has significantly increased over the past 20 years, including those given after low-risk surgery. Unintentional opioid overdoses have also dramatically risen. Excess pills are widely acknowledged as a source of diversion, which accounts for up to 40% of opioid-related overdoses. In the foot and ankle literature, there are no studies looking at the quantity of pain medications that should be prescribed following outpatient surgery. Furthermore, with the increasing use of peripheral nerve blocks, their effect on quantities of narcotics needed after these surgeries have not been explored. This study aims to determine prescribing patterns for common outpatient foot and ankle surgery and whether patients are over or under-prescribed opioids and if so, by how much. Methods: 57 patients undergoing outpatient foot and ankle surgeries were prospectively enrolled. Patients received a spinal neuraxial block and a long-acting popliteal peripheral nerve block, and did not receive ketorolac perioperatively. Patients were excluded if they had a history of chronic pain, or were currently using opioids or muscle relaxers. Enrolled patients received a standard post-operative prescription regimen of 60 tablets of narcotics, 3 days of scheduled ibuprofen, aspirin 81 mg twice a day (or alternate based on risk factors) for DVT prophylaxis, and ondansetron taken as needed. Patients used a pain diary to record when their block wore off and the quantity of narcotic taken. They received surveys at post-operative day (POD) 3, 7, and 14 detailing how many days they took the medication and how many pills were consumed, how their actual pain compared to their expected level of pain, and if they were satisfied with their pain control. Results: At POD 3, compared to their expected level of pain 36 patients had less pain, 15 had the same pain, and 3 had more pain than expected. The mean pain score was 4. Patients first started feeling the block wear off at 0.9 days. Patients averaged 10.3 pills of narcotics in the first 3 days and rated their overall satisfaction with pain control at 8.5. Between days 4-7, patients took an average of 7 pills, and on POD 7, 22 patients were still taking narcotics. At POD 14, patients experienced 74.4% relief of pain compared to their expected pain, and rated their overall satisfaction at 8.2. Patients had an average of 33.5 remaining pills on POD 14 and 13 patients (22.8%) were still taking narcotics. Conclusion: Patients receiving spinal and long-acting popliteal blocks, followed by the prescription regimen described above had excellent pain control after outpatient foot and ankle surgeries. Patients had a high level of satisfaction with their pain control, with many patients describing better pain relief than expected. However, 60 tablets of narcotics were excessive in most cases. We suggest that in patients receiving spinal and long-acting popliteal blocks, 30 tablets of a narcotic would cover the pain needs of most patients. This would provide a small excess in case of need, but would help minimize the risk of narcotic related complications and diversion.

scholarly journals Financial Impact of MRI in Treatment of Foot and Ankle Osteomyelitis

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0001
Author(s):  
Srikanth Divi ◽  
Kelly Hynes ◽  
Douglas Dirschl ◽  
Cody Lee
Keyword(s):  
Lower Extremity ◽  
Clinical Decision Making ◽  
Tertiary Care ◽  
The United States ◽  
Operative Procedures ◽  
Financial Impact ◽  
Foot And Ankle ◽  
Plain Radiographs ◽  
Significant Difference ◽  
The Cost

Category: Ankle, Diabetes, Hindfoot, Lesser Toes, Midfoot/Forefoot, Infection Introduction/Purpose: Osteomyelitis of the foot and ankle is a common condition with a high economic burden in the United States, particularly in the context of diabetes mellitus. The timely and accurate diagnosis of osteomyelitis is important to initiate treatment and possibly reduce overall healthcare costs. Plain radiographs are the initial study of choice given their widespread availability and low cost. Magnetic resonance imaging (MRI) is generally considered the most sensitive imaging modality for detecting osteomyelitis, however it is associated with significant cost and may not change overall treatment as compared to plain radiographs. The purpose of our retrospective study is to determine whether the use of MRI at our institution changed clinical decision making and calculate the financial impact in patients with foot and ankle osteomyelitis. Methods: We retrospectively identified patients at our tertiary care, academic center treated for a diagnosis of osteomyelitis using ICD-9 codes 730.07, 730.17, and 730.27. Demographic data including age, sex, race and ethnicity and patient comorbidities was collected. The use of plain radiographs, MRI, and any operative procedures up to 2 years after the index encounter for each patient were identified. An impact MRI was defined as an MRI that led to an operative procedure within the same admission encounter. The cost of an impact MRI was estimated using the equation: (average MRI cost)*(total MRIs/impact MRIs). Chi- squared test was used to statistically compare patients that underwent procedures in the MRI group vs. those in non-MRI group. Results: 619 patients undergoing osteomyelitis treatment between January 2009 and September 2015 at our institution were identified, of which 40.4% were female and 59.6% were male. 151 patients had a total of 227 MRIs of the lower extremity performed vs. 468 patients that did not have MRIs performed. Of the MRI cohort, 104/151 patients (68.9%) had subsequent operative procedures, whereas in the non-MRI cohort 299/468 patients (63.9%) had subsequent operative procedures (p = 0.26). Of the 227 MRIs performed, 85 were deemed impactful MRIs and 142 were deemed non-impactful MRIs. Average MRI cost at our institution for the lower extremity with and without contrast was $5069.75. Using our previous definition, the cost of an impact MRI was calculated to be effectively $13,539.21. Conclusion: MRI can be an effective modality in aiding the clinical diagnosis of osteomyelitis, however, it can be an unnecessary cost when not used to guide treatment. In our study, we did not find a significant difference in the operative rate between patients undergoing MRIs vs. those that did not. We also found that the effective cost of an MRI that led to a change in treatment was $13,539, almost 2.7 times higher than the average cost of an MRI at our institution.

Maximizing the Value of Electronic Prescription Monitoring Programs

2003 ◽  
Vol 31 (1) ◽  
pp. 41-54 ◽  
Author(s):  
David B. Brushwood
Keyword(s):  
United States ◽  
Pain Management ◽  
Public Health Problem ◽  
Opioid Analgesics ◽  
The United States ◽  
Deterrent Effect ◽  
Electronic Prescription ◽  
Significant Public Health Problem ◽  
Significant Public Health ◽  
Controlled Substance

There is general agreement that the “principle of balance” should guide controlled substance policy and regulation in the United States. Although the diversion of controlled substances from medical to nonmedical purposes is a significant public health problem, overly aggressive controlled substance regulation has been shown to have an unintended deterrent effect on appropriate controlled substance use, including pain management with opioid analgesics. The promotion of effective pain management and the reduction of substance abuse are equally important regulatory objectives. Neither regulatory objective need be sacrificed to achieve the other. Rather, the two objectives must be balanced with each other to assure that necessary pain management is encouraged while drug abuse is curtailed.Approximately 75 million people in the United States suffer from severe pain. Fifty million of these suffer chronic pain, and 25 million suffer acute pain from trauma or surgery. Pain is not merely an uncomfortable symptom.

scholarly journals Digitalization of the Economy: the New Role of Social Media

2021 ◽  
Vol 13 (2) ◽  
pp. 006-026
Author(s):  
Rustem M. Nureev ◽  
◽  
Islam D. Surkhaev ◽  
Keyword(s):  
Social Networks ◽  
Western Europe ◽  
Electoral System ◽  
Developed Countries ◽  
The United States ◽  
The Internet ◽  
Finance Management ◽  
Conflicting Information

The article is devoted to the analysis of social networks, the role of which is constantly growing in the context of the digitalization of the economy. The Internet has become an important prerequisite for their spread. If at the beginning of 1990, even in the most developed countries, less than 1% of the population used the Internet, then by 2020 the level of its prevalence in North America and Western Europe exceeded 90%, and in the countries of East, Southeast and West Asia, and Latin America has exceeded 2/3. We live in a rapidly changing world, when the number of active Internet users exceeded 4.66 billion people in early 2021. The speed of obtaining information is currently an important factor in economic activity. Therefore, contacts are growing rapidly, which is reflected in e-mail, which has become an integral part of modern life, pushing far back other forms of communication (newspapers, mail, telegraph, etc.). The rapid acceleration of conflicting information increases the risk of decision-making, many of which must be made in the face of uncertainty. With the growth of social networks, the density of contacts increases and the importance of a fuller use of network benefits increases. Not only is the number of participants changing, but so is the quantity and quality of the most popular websites. Citizens of modern states are more informed than their previous generations. Conducting an electoral system under such conditions turns out to be a task with many unknowns. In these conditions, voting manipulation takes on new features, which were clearly manifested during the American presidential campaigns in the United States in 2008, 2012, 2016. In addition, opportunities are being created to improve the quality of public finance management by increasing the openness of budgeting at the federal and regional levels, that is, the actual implementation of the Vernon Smith auction in practice, which will be an important step in the formation of a genuine civil society.

I Need a Refill

2020 ◽  
pp. 237-246
Author(s):  
Elissa G. Miller
Keyword(s):  
United States ◽  
Palliative Care ◽  
Pain Management ◽  
Standard Of Care ◽  
The United States ◽  
Opioid Therapy ◽  
Pediatric Palliative Care ◽  
Care Providers ◽  
Patient Risk ◽  
Standard Practices

Opioid misuse, abuse, and diversion are serious concerns due to the risk of addiction and death from overdose. Rising addiction and overdose rates in the United States have led providers to establish a set of standard practices by which they assess patient risk and monitor closely while the patient is receiving opioid therapy for pain management. Pediatric patients and their families are not immune to the risks of opioids, and they should therefore be monitored closely in accordance with the adult standard of care. This chapter discusses universal precautions for opioid prescribing and makes recommendations for pediatric palliative care providers.

Role of Intravenous Ketamine as Adjuvant to Opioids in Refractory Cancer Pain: Case Report

2019 ◽  
Vol 3 (1) ◽  
pp. 49-53
Author(s):  
Yogesh Regmi ◽  
Ganga Sapkota ◽  
Bhawna Wagle
Keyword(s):  
Cancer Pain ◽  
Tissue Injury ◽  
Case Reports ◽  
Opioid Analgesics ◽  
Nmda Receptor Antagonist ◽  
Opioid Therapy ◽  
Chronic Stimulation ◽  
Patients With Cancer ◽  
Nociceptive Input

Cancer pain is caused by continuous tissue injury, which may be due to surgery, infiltration of the surrounding organs including nerves, as well as from mucositis after chemo- or radiotherapy. The pain experienced by cancer patients needs a multimodal approach, including ketamine. Nerve involvement, chronic opioid therapy and continuous nociceptive input cause hyperalgesia. Chronic stimulation of the dorsal root neurons leads to hyperalgesia and resistance (tolerance) to μ opioid analgesics (hyperalgesia-tolerance). The NMDA receptor antagonist ketamine reverses tolerance to morphine. The management of cancer patient’s pain with ketamine as an adjuvant to opioids is presented in case reports of two patients with cancer-related neuropathic pain, in which pain proved untreatable with the usual conventional pain therapies. Ketamine was administered IV route, in addition to morphine and the pain was controlled successfully in these patients. No side-effects were noted except drowsiness which responded to a reduction in the opioids dose.  

Improving State Medical Board Policies: Influence of a Model

2003 ◽  
Vol 31 (1) ◽  
pp. 119-129 ◽  
Author(s):  
Aaron M. Gilson ◽  
David E. Joranson ◽  
Martha A. Maurer
Keyword(s):  
Pain Management ◽  
Inappropriate Prescribing ◽  
Medical Knowledge ◽  
Opioid Analgesics ◽  
The United States ◽  
Long Term Effects ◽  
Controlled Substances ◽  
Regulatory Systems ◽  
State Medical Boards ◽  
State Medical Board

Despite advances in medical knowledge regarding pain management, pain continues to be significantly undertreated in the United States. There are many drug and nondrug treatments, but the use of controlled substances, particularly the opioid analgesics, is universally accepted for the treatment of pain from cancer. Although opioid analgesics are safe and effective in treating chronic pain, there is continued research and discussion about patient selection and long-term effects. A number of barriers in the health care and drug regulatory systems account for the gap between what is known about pain management and what is practiced. Among the barriers are physicians’ fears of being disciplined by state regulatory boards for inappropriate prescribing.State medical boards are in a unique position not only to address physicians’ concerns about being investigated, but also to encourage pain management. Prior to 1989, a few state medical boards had policies relating to controlled substances or pain. Subsequently, state medical boards began adopting policies regarding the prescribing of opioids for the treatment of pain; many of these specifically addressed physicians’ fear of regulatory scrutiny.

scholarly journals Updates on chronic non-cancer pain management in face of the opioid crisis

2018 ◽  
Vol 87 (1) ◽  
pp. 46-48
Author(s):  
Gayathri Sivakumar ◽  
Alexandra Budure ◽  
Elise Quint
Keyword(s):  
Pain Management ◽  
Cancer Pain ◽  
Significant Proportion ◽  
Opioid Analgesics ◽  
Opioid Therapy ◽  
Prescribing Patterns ◽  
Steady Increase ◽  
Prescribing Practices ◽  
Health Crisis ◽  
Canadian Guideline

Chronic pain not associated with malignancy is experienced by a significant proportion of the Canadian population. As the quality of life and physical functioning are markedly impaired in patients with chronic non-cancer pain, clinicians have commonly turned to opioid therapy for pain management. Since the 1990s, the steady increase in dispensing of prescription opioids has paralleled trends in opioid-related hospitalizations, overdoses, and fatalities. In fact, over-prescription and longterm opioid therapy are among the many root causes fueling Canada’s rise in opioid addiction and opioid-related deaths. Physicians and medical regulators have responded to this public health crisis by developing the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. The new evidence-based guideline aims to encourage safe prescribing practices, reduce and eliminate the use of opioid analgesics and promote non-opioid pharmacotherapy. While clear clinical guidelines will optimize physician prescribing patterns, it is imperative to recognize the need for non-pharmacological modalities for pain management, treatment, and care to holistically address the complex roots of opioid abuse.

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