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Postoperative Opioid-Prescribing Practice in Limb Preservation Surgery

Brandon M. Brooks The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH.
Columbia VA Health Care System, Columbia, SC.

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 DPM, MPH
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Chia-Ding Shih California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA.

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Reed W. R. Bratches The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH.

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Kevin T. Pham Community Health Alliance of Pasadena, Pasadena, CA.

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Bradley M. Brooks USA Health, Mobile, AL.

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Lili Hooshivar California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA.

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Kristina B. Wolff The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH.

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 PhD, MPH

Background: Limb preservation surgery affects more than 100,000 Americans annually. Current postoperative pain management prescribing practices of podiatric physicians in the United States are understudied. We examined prescribing practices for limb preservation surgery to identify prescriber characteristics' that may be associated with postoperative opioid-prescribing practices.

Methods: We administered an anonymous online questionnaire consisting of five patient scenarios with limb preservation surgery commonly performed by podiatric physicians. Respondents provided information about their prescription choice for each surgery. Basic provider demographics were collected. We developed linear regression models to identify the strength and direction of association between prescriber characteristics and quantity of postoperative opioid “pills” (dosage units) prescribed at surgery. Logistic regression models were used to identify the odds of prescribing opioids for each scenario.

Results: One hundred fifteen podiatric physicians completed the survey. Podiatric physicians reported using regional nerve blocks 70% to 88% of the time and prescribing opioids 43% to 67% of the time across all scenarios. Opioids were more commonly prescribed than nonsteroidal anti-inflammatory drugs and anticonvulsants. Practicing in the Northeast United States was a significant variable in linear regression (P = .009, a decrease of 9–10 dosage units) and logistic regression (odds ratio, 0.23; 95% confidence interval, 0.07–0.68; P = .008) models for the transmetatarsal amputation scenario.

Conclusions: Prescribing practice variation exists in limb preservation surgery by region. Podiatric physicians reported using preoperative regional nerve blocks more than prescribing postoperative opioids for limb preservation surgeries. Through excess opioid prescribing, the diabetes pandemic has likely contributed to the US opioid epidemic. Podiatric physicians stand at the intersection of these two public health crises and are equipped to reduce their impact via preventive foot care and prescribing nonopioid analgesics when warranted.

Corresponding author: Brandon M. Brooks, DPM, MPH, DABPM CAQ-Podiatric Surgery, Columbia VA Health Care System, Columbia, SC.
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