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 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]

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

Excess Opioid Disposal Following Orthopaedic Surgery: A Randomized Clinical Trial

2020 ◽  
pp. 193864002098092
Author(s):  
Cornelia Keyser ◽  
Abhiram Bhashyam ◽  
Abdurrahman Abdurrob ◽  
Jeremy T. Smith ◽  
Eric Bluman ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Orthopaedic Surgery ◽  
Control Group ◽  
Foot And Ankle ◽  
Opioid Medication ◽  
Ankle Surgery ◽  
Randomized Control ◽  
Level I ◽  
To Receive ◽  
Experimental Group

Background Previous research indicates low disposal rates of excess postoperative narcotics, leaving them available for diversion or abuse. This study examined the effect of introducing a portable disposal device on excess opiate opioid disposal rates after lower extremity orthopaedic surgery. Methods This was a single site randomized control trial within an outpatient orthopaedic clinic. All patients 18 years or older, undergoing outpatient foot and ankle surgery between December 1, 2017 and August 1, 2018 were eligible. Patients were prospectively enrolled and randomized to receive standard opioid disposal instructions or a drug deactivation device at 2-week postoperative appointments. Participants completed an anonymous survey at 6-week postoperative appointments. Results Of the 75 patients surveyed, 68% (n = 26) of the experimental group and 56% (n = 21) of the control group had unused opioid medication. Of these, 84.6% of patients who were given Deterra Drug Deactivation System deactivation pouches safely disposed of excess medication, compared with 38% of controls (P = .003). When asked if they would use a disposal device for excess medication in the future, 97.4% (n = 37) of the experimental and 83.8% (n = 31) of the control group reported that they would. Conclusions Providing a portable disposal device with postoperative narcotic prescriptions may increase safe disposal rates of excess opioid medication following lower extremity orthopaedic surgery. Levels of Evidence Level I

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]

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.

Prospective Evaluation of Opioid Use After Adoption of a Prescribing Guideline for Outpatient Foot and Ankle Surgery

2019 ◽  
Vol 40 (11) ◽  
pp. 1260-1266
Author(s):  
Abhiram R. Bhashyam ◽  
Cornelia Keyser ◽  
Christopher P. Miller ◽  
Jennifer Jacobs ◽  
Eric Bluman ◽  
...  
Keyword(s):  
Opioid Consumption ◽  
Prescription Opioid ◽  
Foot And Ankle ◽  
Opioid Use ◽  
Level Of Evidence ◽  
Opioid Prescription ◽  
Provider Group ◽  
Use Patterns ◽  
Ankle Surgery ◽  
Pill Counts

Background: In 2016, our provider group adopted an initial prescription opioid maximum guideline to reduce overprescription of opioids. The purpose of this study was to prospectively assess opioid consumption patterns following implementation of this guideline in patients undergoing outpatient foot and ankle surgery. Methods: Over a 1-year period, we prospectively analyzed opioid prescription and use patterns of 303 consecutive patients. Opioid consumption was verified by pill counts completed at the 2- and 6-week postoperative visits. The morphine equivalent dose was calculated for each prescription and converted to the equivalent 5-mg oxycodone “pill.” We used the regression coefficients from a regression model of opioid consumption to create a revised guideline for maximum initial opioid prescriptions based on patient age, bony vs nonbony procedure, and anatomic location (forefoot/midfoot/hindfoot/ankle). Results: On average, 37.4 pills were prescribed and 18.9 pills used (47.6% utilization). Only 17.2% of patients used their full prescription quantity. By 2 weeks, 88% of patients no longer used opioids. Only 1.3% of patients used prescription opioids beyond 6 weeks. Independent risk factors for increased opioid consumption were younger age ( P = .003), male sex ( P = .007), recent preoperative opioid use ( P = .019), bony procedures ( P < .001), and ankle/hindfoot procedures ( P = .016 and P < .001). Conclusion: This study showed the amount of opioid consumption for patients undergoing foot and ankle procedures. We present a modified guideline for the maximum initial prescription of opioids following outpatient foot and ankle procedures that can be used as a benchmark for further study in decreasing overprescribing. Level of Evidence: Level II, prospective observational cohort study.

Influence of Complications and Revision Surgery on Fulfillment of Expectations in Foot and Ankle Surgery

2021 ◽  
pp. 107110072098523
Author(s):  
Bopha Chrea ◽  
Jonathan Day ◽  
Jensen Henry ◽  
Elizabeth Cody ◽  
Scott Ellis ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Pain Management ◽  
Postoperative Complications ◽  
Postoperative Complication ◽  
Foot And Ankle ◽  
Level Of Evidence ◽  
Initial Surgery ◽  
Ankle Surgery ◽  
Patient Reported ◽  
The Impact

Background: Fulfillment of patients’ expectations following foot and ankle surgery has been previously studied, and shown to be an effective modality in assessing patient-reported outcomes (PROs). Although this assessment has been shown to correlate well with patient satisfaction and other validated PROs, the impact of postoperative complications on fulfillment of expectations is unknown. The aim of this study is to therefore investigate the impact of postoperative complications on fulfillment of patients’ expectations. Methods: Preoperatively, patients completed a validated Foot and Ankle Expectations Survey consisting of 23 questions encompassing domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. Chart review was performed to identify patient demographics, comorbidities, pain management, and postoperative complications, which were classified as minor (infection requiring antibiotics) or major (return to operating room for revision, deep infection). FP in patients with a complication was compared to patients who did not experience a complication. In addition, the Foot and Ankle Outcomes Score (FAOS), satisfaction, and Delighted-Terrible scale (how they would feel if asked to spend the rest of their life with their current foot/ankle symptom) were collected at final follow-up. Of the 271 patients (mean age 55.4 years, 65% female), 31 (11.4%, mean age 53.6, 58% female) had a postoperative complication: 25 major (19 revisions, 6 deep infections requiring irrigation and debridement), 4 minor (4 superficial infections requiring antibiotics), and 2 major and minor (revision and superficial infection). Average time from complication to completion of fulfillment survey was 15 (±3.6) months. The groups were similar in diagnoses. Results: Complications were associated with significantly worse FP (0.69 ± 0.45 vs 0.86 ± 0.40, P = .02). Having a complication significantly correlated with worse satisfaction, Delighted-Terrible scale, and FP ( P < .001). FAOS domains were similar between groups preoperatively; postoperatively, patients without complications had significantly higher Activities of Daily Living and Quality of Life scores ( P < .05). Demographically, there was no difference in age, sex, body mass index, Charlson Comorbidity Index, depression/anxiety, or pain management between the 2 groups. Conclusion: Our data suggests that postoperative complications following foot and ankle surgery were associated with worse patient-reported fulfillment of their operative expectations even after recovery from the initial surgery and complication. This finding is independent of preoperative expectations, and correlates with patient satisfaction with their procedure. Therefore, while patient-perceived fulfillment following foot and ankle surgery is multifactorial, the incidence of a postoperative complication negatively impacts fulfillment as well as satisfaction following surgery. Level of Evidence: Level II, prospective comparative series.

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