scholarly journals Self-Reported Pain Tolerance and Opioid Pain Medication Use after Foot and Ankle Surgery

2019 ◽  
Vol 4 (2) ◽  
pp. 2473011419S0000
Author(s):  
Laura E. Sokil ◽  
Elizabeth McDonald ◽  
Ryan G. Rogero ◽  
Daniel J. Fuchs ◽  
Steven M. Raikin ◽  
...  
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Pain Control ◽  
Pain Threshold ◽  
Postoperative Pain Management ◽  
Pain Medication ◽  
Pain Tolerance ◽  
Foot And Ankle ◽  
Ankle Surgery ◽  
Perceived Pain

Category: Pain Management Introduction/Purpose: The opioid epidemic in the United States continues to take lives. As one of the top prescribing groups, orthopaedic surgeons must tailor post-surgical pain control to minimize the potential for harm from prescription opioid use. Patients often reference their own pain threshold as a benchmark for how they will tolerate the pain of surgery, but current literature suggests that there is not a significant correlation between an individual’s perceived pain threshold and their actual threshold for heat stimulus. The purpose of this study was to determine whether there is a correlation between a patient’s self- reported pain tolerance and their actual prescription narcotic medication usage after foot and ankle surgery. Methods: This was a prospective cohort study of adult patients that underwent outpatient foot and ankle surgeries performed by 5 fellowship-trained foot and ankle surgeons at a large, multispecialty orthopaedic practice over a one year period. Demographic data, procedural details and anesthesia type were collected. Narcotic usage data including number of pills dispensed and pill counts performed at the first postoperative visit were obtained. Patients were contacted via email or telephone between 7-19 months postoperatively, and asked to respond to the validated statement “Pain doesn’t bother me as much as it does most people” by choosing “strongly disagree”, “disagree”, “neither”, “agree” or “strongly agree”. Patients scored their pain threshold on a scale of 1- 100 with 0 being “pain intolerant” and 100 a ”high pain threshold" and ranked their expectations of the pain after surgery and satisfaction with pain management on respective five-point Likert scales. Data was analyzed using a Spearman’s correlation. Results: Of the 486 patients who completed surveys, average age was 51.24 years, 32.1% were male and 7.82% current smokers. After controlling for age and anesthesia type, both agreement with the validated statement and higher pain tolerance score had a weak negative correlation with pills taken (r=-0.13, p=0.004 and r=-0.14, p=0.002, respectively); patients with higher perceived pain thresholds took fewer opioid pills after surgery (Table 1). Correlation between high expectations of postoperative pain and pills taken was weakly negative (r=-0.28, p=<0.001) (Table 1). Patients who found surgery more painful than they expected took less pain medication. There was a small, positive correlation between pain tolerance and satisfaction with pain management (r=0.12, p=0.008), indicating that patients with a relatively high pain tolerance had more satisfaction (Table 1). Conclusion: Assessment of both subjective description and quantitative score of a patient’s pain threshold prior to surgery may assist the surgeon in tailoring postoperative pain control regimens. Unexpectedly, patients who found surgery less painful than expected actually took a greater number of opioid pills. This may highlight an educational opportunity regarding postoperative pain management in order to reduce narcotic requirement. Setting expectations on safe utilization of prescribed pain medications may also increase satisfaction. This study provides useful information for surgeons to customize pain management regimens and to perform effective preoperative education and counseling regarding postoperative pain management. [Table: see text]

scholarly journals Self-Reported Pain Tolerance and Opioid Pain Medication Use after Foot and Ankle Surgery

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0040
Author(s):  
Laura E. Sokil ◽  
Ryan Rogero ◽  
Elizabeth McDonald ◽  
Daniel Fuchs ◽  
Brian S. Winters ◽  
...  
Keyword(s):  
Pain Management ◽  
Pain Threshold ◽  
Multivariate Analyses ◽  
Pain Tolerance ◽  
Qualitative Assessment ◽  
Prescription Opioid ◽  
Foot And Ankle ◽  
Opioid Medication ◽  
Ankle Surgery ◽  
Perceived Pain

Category: Opioid/Pain Management Introduction/Purpose: As one of the top prescribing groups of opioid pain medication, orthopaedic surgeons must tailor post- surgical pain control to minimize the potential for prescription opioid abuse. Patients generate an idea of their own pain threshold relative to others’ based on how they tolerate similar painful experiences, but current literature suggests that there is not a significant correlation between an individual’s perceived pain threshold and their actual tolerance for pain stimulus. The purpose of this study was to determine whether there is a correlation between a patient’s self-reported pain tolerance and their actual prescription opioid medication usage after foot and ankle surgery. Methods: This is a retrospective follow-up of a prospective cohort study of adult patients that underwent outpatient foot and ankle surgeries performed by 5 fellowship-trained foot and ankle surgeons at a multispecialty orthopaedic practice over a one-year period. Number of opioid pills dispensed, pills consumed at the first postoperative visit, patient demographic data, and procedural data were obtained. Patients were contacted via email or telephone postoperatively and asked to respond to the qualitative statement “Pain doesn’t bother me as much as it does most people” by choosing “strongly disagree”, “disagree”, “neither”, “agree” or “strongly agree”. Patients also scored their quantitative pain threshold on a scale of 0-100 with 0 being “very pain intolerant” and 100 a “very high pain tolerance” and rated their expectations of postoperative pain and satisfaction with pain management on five-point Likert scales. Data was analyzed using various tests, including Spearman’s correlations and bivariate and multivariate analyses. Results: Of 700 patients responding, the average age was 50.8 years and 34.7% were male. There was a significant, weakly negative (p=0.003, r=-.112) correlation between a higher qualitative assessment of pain threshold and number of pills consumed; patients with higher perceived pain thresholds took fewer opioid pills after surgery. Logistic bivariate regression predicting the top 25% of opioid pill consumers showed that higher qualitative assessment of pain threshold was negatively predictive of being among the top 25% of opioid pill consumers (OR 0.839, p=0.041). Multivariate analyses among the total cohort demonstrated a significant, negative association (p=0.005) between qualitative assessment of pain threshold and opioid pill consumption, while past narcotic usage time positively predicted the top 25% of opioid pill consumers (OR 1.224, p=.006). Conclusion: Prediction of patients’ postoperative narcotic requirement is complex and dependent on many patient-derived and systemic factors, but our study has shown that there is a negative association between patients’ self-reported qualitative pain tolerance with postoperative opioid consumption after foot and ankle surgery. This study presents a useful preoperative strategy for clinicians to customize postoperative pain management, further educate patients on responsible use of opioid medication, and reduce overall opioid prescriptions.

scholarly journals Postoperative Narcotic Prescription Practice in Orthopedic Foot and Ankle Surgery

2018 ◽  
Vol 3 (3) ◽  
pp. 247301141877594
Author(s):  
Thomas M. Hearty ◽  
Paul Butler ◽  
John Anderson ◽  
Donald Bohay
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Postoperative Pain Management ◽  
Pain Medication ◽  
Foot And Ankle ◽  
Prescribing Practices ◽  
Nerve Blocks ◽  
Opioid Prescription ◽  
Health Crisis ◽  
Ankle Surgery

Background: The misuse and abuse of opioid pain medications have become a public health crisis. Because orthopedic surgeons are the third highest prescribers of opioids, understanding their postoperative pain medication prescribing practices is key to solving the opioid crisis. To this end, we conducted a study of the variability in orthopedic foot and ankle surgery postoperative opioid prescribing practice patterns. Methods: Three hundred fifty orthopedic foot and ankle surgeons were contacted; respondents completed a survey with 4 common patient scenarios and surgical procedures followed by questions regarding typical postoperative pain medication prescriptions. The scenarios ranged from minimally painful procedures to those that would be expected to be significantly more painful. Summaries were calculated as percentages and chi-square or Fisher exact tests were used to compare survey responses between groups stratified by years in practice and type of practice. Results: Sixty-four surgeons responded to the survey (92.8% male), 31% were in practice less than 5 years, 34% 6 to 15 years and 34% more than 15 years. For each scenario, there was variation in the type of pain medication prescribed ( scenario 1: 17% 5 mg hydrocodone, 22% 10 mg hydrocodone, 52% oxycodone, and 3% oxycodone sustained release [SR]; scenario 2: 15% 5 mg hydrocodone, 13% 10 mg hydrocodone, 58% oxycodone, and 9% oxycodone SR; scenario 3: 11% 5 mg hydrocodone, 13% 10 mg hydrocodone, 56% oxycodone, and 14.1% oxycodone SR; scenario 4: 3% 5 mg hydrocodone, 5% 10 mg hydrocodone, 44% oxycodone, and 45% oxycodone SR) and the number of pills dispensed. Use of multimodal pain management was variable but most physicians use regional nerve blocks for each scenario (76%, 87%, 69%, 94%). Less experienced surgeons (less than 5 years in practice) supplement with tramadol more for scenario 1 ( P = .034) as well as use regional nerve blocks for scenario 2 ( P = .039) more than experienced surgeons (more than 15 years in practice). Conclusion: It is evident that variation exists in narcotic prescription practices for postoperative pain management by orthopedic foot and ankle surgeons. With new AAOS guidelines, it is important to try to create some standardization in opioid prescription protocols.

scholarly journals How Will the Foot and Ankle Orthopedic Community Respond to the Growing Opioid Epidemic?

2018 ◽  
Vol 3 (3) ◽  
pp. 247301141876446 ◽  
Author(s):  
Gabrielle S. Donahue ◽  
Noortje Catherine Hagemeijer ◽  
Anne Holly Johnson
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Orthopedic Surgery ◽  
Clinical Guidelines ◽  
Postoperative Pain Management ◽  
Consumption Patterns ◽  
Prescribing Patterns ◽  
Opioid Epidemic ◽  
Foot And Ankle ◽  
Ankle Surgery

In the midst of the current opioid crisis, it has become critically important to properly manage opioid-prescribing patterns for the treatment of postoperative pain. There is currently a scarcity of literature specifying prescription and consumption patterns following orthopedic surgery and specifically foot and ankle surgery. Clinical guidelines for postoperative pain management are deficient.

Self-Reported Pain Tolerance and Opioid Pain Medication Use After Foot and Ankle Surgery

2020 ◽  
pp. 193864002097037
Author(s):  
Laura E. Sokil ◽  
Ryan G. Rogero ◽  
Elizabeth L. McDonald ◽  
Daniel Corr ◽  
Daniel Fuchs ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Threshold ◽  
Statistical Significance ◽  
Pain Tolerance ◽  
Opioid Consumption ◽  
Prescription Opioid ◽  
Bivariate Analysis ◽  
Foot And Ankle ◽  
Opioid Use ◽  
Ankle Surgery

Background: Orthopaedic surgeons must consider their postoperative pain management strategies to minimize harm from prescription opioid use. Patients often reference their pain threshold to predict how they will tolerate surgical pain and the need for postoperative analgesia, but the direct relationship between these factors has not yet been studied. The purpose of this study was to determine the relationship between patients’ self-reported pain tolerance and prescription opioid usage after foot and ankle surgery. Methods: This is a retrospective follow-up of a prospective cohort study of adult patients who underwent outpatient foot and ankle surgeries. Patient and procedural demographics, opioid pills dispensed, and opioid pills consumed by the first postoperative visit were obtained. Patients were contacted at a mean of 13.1 ± 4.0 months postoperatively and asked to respond to the qualitative statement “Pain doesn’t bother me as much as it does most people.” Patients were also asked their quantitative pain threshold (0-100), with 0 being “very pain intolerant” and 100 being a “very high pain tolerance,” as well other questions regarding past surgical and narcotic consumption history. Results: Of the 700 survey respondents, the average age was 50.9 years and 34.7% were male. Bivariate analysis determined that predictors of lower postoperative opioid consumption included higher quantitative ( P = .047) and qualitative ( P = .005) pain tolerance scores. Multivariate analysis for the entire cohort demonstrated that higher qualitative pain threshold was associated with lower postoperative opioid consumption ( P = .005) but this did not meet statistical significance as an independent predictor of the top quartile of pill consumers. Conclusion: Assessment of both qualitative and quantitative score of patients’ pain threshold prior to surgery may assist the surgeon in tailoring postoperative pain control. Additionally, asking this question can create an opportunity for educating patients regarding responsible utilization of narcotic medication. Levels of Evidence: Level III

scholarly journals Randomized Study of the Effect of Initial Ropivacaine Dosage during Continuous Popliteal Nerve Blocks on Rebound Pain in Foot and Ankle Surgery

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0006
Author(s):  
Ryan Rogero ◽  
Elizabeth McDonald ◽  
Steven M. Raikin ◽  
Daniel Fuchs ◽  
Rachel J. Shakked ◽  
...  
Keyword(s):  
Side Effects ◽  
Postoperative Pain ◽  
Pain Score ◽  
Local Anesthetic ◽  
Pain Control ◽  
Foot And Ankle ◽  
Nerve Blocks ◽  
Anesthetic Concentration ◽  
Ankle Surgery ◽  
Perceived Pain

Category: Basic Sciences/Biologics, Anesthesia/Pain Control Introduction/Purpose: Rebound pain, the quantifiable difference in pain experienced after nerve block resolution, can be a substantial component of postoperative pain, opioid intake, sleep disturbances, and patient satisfaction. A relatively higher concentration initial local anesthetic bolus may contribute to this phenomenon, as the transition from an entirely numb and painless limb to a partially numb limb may lead to greater perceived pain following block resolution. In contrast, patients experiencing some level of background pain immediately following surgery due to a lower concentration initial bolus may have less perceived pain after block resolution. The purpose of this study is to evaluate the influence of the initial local anesthetic concentration in continuous popliteal nerve blocks on rebound pain and other postoperative variables in foot and ankle surgery. Methods: Following IRB approval, patients undergoing outpatient foot and ankle procedures requiring continuous popliteal nerve blocks under the care of a single fellowship-trained foot & ankle surgeon were identified. Subjects were randomized and blinded to either the standard (0.5%) or low-dose (0.2%) initial ropivacaine bolus, both being followed by a continuous 0.2% ropivacaine catheter infusion. From postoperative days 1 to 7, subjects recorded their hourly visual analog scale (VAS) pain level out of 100, perceived pain relief from the block, and satisfaction with pain control, as well as daily narcotic intake and other postoperative side effects, through an electronic survey. Rebound pain was scored according to a published method by subtracting the lowest VAS pain score during the 12 hours prior to the subject’s determination of block resolution from the highest VAS pain score in the 12 hours after resolution. 69 subjects completed the study. Outcomes were compared using Student’s t-tests. Results: Thirty-four subjects received a standard initial 0.5% ropivacaine bolus, while 35 received a 0.2% bolus. Chi-square testing and t-tests revealed no difference in any preoperative patient variables or procedural type/location between groups. Subjects receiving the lower 0.2% ropivacaine bolus had a lower rebound pain score (47.6) than those receiving the standard ropivacaine bolus (51.0), though not significantly (p=.679). The group receiving the lower concentration bolus only reported a higher mean VAS pain at 72 hours following surgery (39.6 vs. 25.7, p=.044) and more pain interference with sleep (p=.015) on postoperative day 5. The groups did not differ significantly (p>.05) on any day in terms of morphine equivalent units (MEUs) consumed, satisfaction with pain control, nausea, constipation, or nerve-related symptoms of tingling, numbness, and hypersensitivity. Conclusion: The utilization of a lower concentration initial local anesthetic bolus in continuous peripheral nerve blocks in foot and ankle surgery did not significantly lower rebound pain, but provided similar postoperative pain control as a standard local anesthestic bolus concentration. Further investigation with larger cohorts is needed to further optimize local anesthetic concentration in continuous nerve blocks in order to limit postoperative pain, side effects, and opioid intake following foot and ankle surgery.

scholarly journals Our first Experience of Continuous Fascia Iliaca Compartment Block for Post Operative Analgesia in a Case of Fracture Femur in TU Teaching Hospital

2018 ◽  
Vol 16 (2) ◽  
pp. 248-250
Author(s):  
Bigen Man Shakya ◽  
Ninadini Shrestha
Keyword(s):  
Case Report ◽  
Pain Management ◽  
Postoperative Pain ◽  
Teaching Hospital ◽  
Postoperative Pain Management ◽  
The Elderly ◽  
Pain Medication ◽  
Fracture Femur ◽  
Fascia Iliaca Compartment Block

The postoperative pain management in the elderly is challenging due to comorbidities and change in physiology due to age itself. This limit the use of medication which include pain medication also. The fascia iliaca compartment block has been described in the literature for fracture of femur. It has even been safely used by non anaesthesiologist also. To our knowledge, we did not find any case report of continuous fascia iliaca compartment block published in Nepal. This is our first experience of successful continous fasicia iliaca compartment block in case of 89 year old lady with multiple co morbidities in whom traditional pain medication might be difficult to use. We encourage to practice this block which is both safe and easy to perform with good results.

scholarly journals Outcome Following Lower Extremity Nerve Block during Foot and Ankle Surgery: A Systematic Review

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0022
Author(s):  
Arianna L. Gianakos ◽  
Filippo Romanelli ◽  
Malaka Badri ◽  
Naina Rao ◽  
Bart Lubberts ◽  
...  
Keyword(s):  
Systematic Review ◽  
Pain Management ◽  
Postoperative Pain ◽  
Continuous Infusion ◽  
Nerve Block ◽  
Opioid Consumption ◽  
Foot And Ankle ◽  
Complication Risk ◽  
Prospective Comparison ◽  
Ankle Surgery

Category: Ankle; Other Introduction/Purpose: The purpose of this study was to perform a systematic review of the current literature assessing the management of pain with various block techniques in the perioperative period during elective foot and ankle surgery. Methods: A review of the literature was performed according to the PRISMA guidelines. Medline, Embase, and Cochrane databases were searched on October 1, 2019. Studies were identified by using synonyms for ‘foot’, ‘ankle’, ‘pain management’, ‘opioid’ and ‘nerve block’. Inclusion criteria were studies that 1) reported and compared the outcomes following various types of peripheral nerve blocks in in foot and ankle surgery, 2) were published in the English language, and 3) were published within the last 10 years. Results: Twenty-four articles evaluating 4,640 patients were included. Sixty-seven percent were randomized controlled trials, 17% were prospective comparison studies, and 17% were retrospective comparison studies. Nerve block techniques included: femoral, adductor canal, sciatic, popliteal, saphenous, and ankle. Ropivacaine and bupivacaine were most commonly utilized. Postoperative opioid consumption and postoperative pain levels were reduced with use of PNB when compared with systemic/local anesthesia, in patients receiving combined popliteal/femoral block, and in patients receiving continuous infusion popliteal block [Table 1, Table 2]. Studies demonstrated higher satisfaction with PNB, continuous infusion, and dual injections [Table 3]. One study reported 7% neurologic related complication risk and demonstrated a higher complication rate when with popliteal versus ankle block. All other studies were equivocal or failed to mention complications. Conclusion: Optimal pain management for elective foot and ankle surgery remains controversial and an ideal protocol from a risk-benefit perspective regarding use of PNB has yet to be established. Our study demonstrates improvements in postoperative pain levels, opioid consumption, and length of stay in patients receiving a PNB when compared with systemic anesthesia. Combined PNB and dual catheter administration may improve outcomes. Unfortunately, little data has been published on risks and tradeoffs in order to help guide patients and surgeons with a well informed shared decision making model. Future studies are needed to better clarify any respective tradeoffs to these options. [Table: see text]

Acute paediatric pain management

2017 ◽  
Author(s):  
Tom G. Hansen
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Acute Pain ◽  
Regional Anaesthesia ◽  
Pain Threshold ◽  
Age Groups ◽  
Postoperative Pain Management ◽  
Psychological Needs ◽  
Long Term Effects

Paediatric pain management has made great strides in the past few decades in the understanding of developmental neurobiology, developmental pharmacology, the use of analgesics in children, the use of regional techniques in children, and of the psychological needs of children in pain. The consequences of a painful experience on the young nervous system are so significant that long-term effects can occur, resulting in behavioural changes and a lowered pain threshold for months after a painful event. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain are constantly being refined, with newer drugs being used alone and in combination with other drugs, and continue to be explored. Systemic opioids, paracetamol, non-steroidal anti-inflammatories, and regional anaesthesia alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are often best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The safe and effective management of pain in children includes the prevention, recognition, and assessment of pain; early and individualized treatment; and evaluation of the efficacy of treatment. This chapter discusses selected topics in paediatric acute pain management, with more specific emphasis placed on pharmacology and regional anaesthesia in the treatment of acute postoperative pain management.

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