Background: Clinicians, governmental agencies, patients, and pharmaceutical companies all contribute to the United States' opioid epidemic. These same stakeholders can make meaningful contributions to resolve the epidemic by identifying ineffective habits and encouraging change. The purpose of this study was to determine if postoperative opioid prescribing practice variation exists in foot and ankle surgery. We also aimed to identify if demographic characteristics of podiatric foot and ankle surgeons were associated with their postoperative opioid prescribing practices. Methods: We administered an open, voluntary, anonymous, online questionnaire distributed on the internet via Qualtrics, an online survey platform. The questionnaire consisted of six foot and ankle surgery scenarios followed by a demographics section. We invited Podiatric foot and ankle surgeons practicing in the United States to complete the questionnaire via email from the American Podiatric Medical Association's membership list. Respondents selected the postoperative opioid(s) that they would prescribe at the time of surgery, as well as the dose, frequency, and number of "pills" (dosage units). We developed multiple linear regression models to identify associations between prescriber characteristics and two measures of opioid quantity: dosage units and MME. Results: Eight hundred and sixty podiatric foot and ankle surgeons completed the survey. The median number of dosage units never exceeded 30 regardless of the foot and ankle surgery. Years in practice correlated with reduction in opioid dosage units prescribed at the time of surgery. Conclusions: Postoperative opioid prescribing practice variation exists in foot and ankle surgery. In comparison to the orthopedic community, podiatric foot and ankle surgeons prescribe approximately 25% fewer opioids at the time of surgery than orthopedic foot and ankle surgeons. Further research is warranted to determine if additional education is needed for young surgeons.
The topic of pain management remains a minor component of the formal education and training of residents and physicians in the United States. Misguided attitudes concerning acute and chronic pain management, in addition to reservations about the legal aspects of pain management, often translate into a “fear of the unknown” when it comes to narcotic prescription. The intentionally limited scope of this review is to promote an understanding of the laws regulating pain management practices in the United States and to provide recommendations for appropriate pain management assessment and documentation based on the Model Policy for the Use of Controlled Substances for the Treatment of Pain established by the Federation of State Medical Boards of the United States. (J Am Podiatr Med Assoc 100(6): 511–517, 2010)
Neuropathologic changes may occur in the nervous system due to long-term substance use, leading to functional disability with altering of balance. We know little about substance-related mechanisms that can cause movement disorders. This study investigated the effects of plantar foot sensation and balance on physical performance as an effect of substance use in detoxified patients.
Twenty-three users of cannabis, volatile agents, or narcotic/stimulant agents alone or in combination for at least 1 year (mean age, 27.6 years) and 20 healthy volunteers (mean age, 24.6 years) were included. Participant evaluations were implemented immediately after the detoxification process with psychiatrist approval. Depression, state-trait anxiety, and fear of movement levels were evaluated with the Beck Depression Inventory, State-Trait Anxiety Inventory, and Tampa Scale for Kinesiophobia, respectively. Plantar foot sensations were evaluated with light touch, two-point discrimination, and vibration examinations. Balance was assessed with balance software and a balance board and force platform. Balance path, balance path distance, and center of pressure were recorded. Physical performance was evaluated with the Timed Up and Go (TUG) test in the final step.
There was a significant difference in two-point discrimination of patients versus controls (P < .05). Significant differences were also found in balance values, particularly in the sagittal direction (P < .05). TUG test results of patients compared with controls showed a negative influence on physical function (P < .05).
Detailed examination should be performed to understand movement disorders in substance users. Herein, substance users had impaired two-point discrimination and sagittal balance reciprocally. Thus, customized physiotherapy approaches to substance users should be considered to improve their movement disorders.
Anesthetics containing epinephrine have long been thought unsuitable for use in the foot and, particularly, the digits. However, research suggests that epinephrine use is beneficial in the appropriately selected patient. These benefits include a decreased local anesthetic plasma concentration; an increased duration of anesthesia, with a decreased need for additional narcotic use after surgery; decreased development of hemorrhage and postoperative hematoma, without occlusion of vessels; and a lack of complications (in millions of patients reported on in the literature). A retrospective review of more than 150 patients receiving local anesthetics containing epinephrine revealed no complications in the foot and ankle. (J Am Podiatr Med Assoc 93(2): 157-160, 2003)
In the physical examination of the patient suspected of having tarsal tunnel syndrome, the podiatric physician relies on Tinel’s sign: tapping the posterior tibial nerve in the tarsal tunnel should produce a distally radiating sensation if the nerve is pathologically compressed at this location. The American College of Rheumatology recognizes fibromyalgia as a condition characterized by multiple “tender points” on physical examination. This report compares the locations of the 18 critical diagnostic fibromyalgia points with known sites of anatomical entrapment of peripheral nerves in the lower extremity. We also describe a patient with both fibromyalgia and tarsal tunnel syndrome. Tinel’s sign in the lower extremity is a valid technique for assessing peripheral nerve compression in the patient with fibromyalgia. (J Am Podiatr Med Assoc 94(4): 400–403, 2004)
The unpleasant and subjective sensation resulting from a noxious sensory stimulus defines the phenomenon of pain. The podiatric physician is no stranger to the difficulties in achieving optimal pain therapy. Podiatric physicians must develop analgesic regimens to treat patients with acute, chronic, and postoperative pain. Because opioid therapy is the cornerstone of the pharmacologic management of acute and chronic pain, this review focuses on the prescribing of opioid analgesics to treat lower-extremity pain. The pharmacology of frequently prescribed opioids is introduced. Then, criteria for selecting appropriate opioid analgesics as found in the current medical literature are reported. Finally, a review of the literature describing legal and ethical considerations regarding the prescribing of opioid analgesics is presented. (J Am Podiatr Med Assoc 96(4): 367–373, 2006)
Adverse drug effects are common in elderly patients but can often be avoided. Judicious prescribing practices require the clinician to be aware of age-related changes in drug absorption, distribution, metabolism, and elimination. Clinicians may need to adjust drug dose, frequency, or the choice of drug altogether as they consider the physiologic changes of aging. This article reviews prescribing situations with elderly patients commonly encountered by the podiatric physician. Strategies for medication management are provided to minimize the risk of adverse drug events in the older patient. (J Am Podiatr Med Assoc 94(2): 90-97, 2004)
Systemic lupus erythematosus is an autoimmune disorder that affects several organs and systems in the human body. Digital gangrene is known to be a rare and severe complication of systemic lupus erythematosus that could lead to amputation. We report a case of an adolescent who presented with an autoimmune disorder and multiple comorbidities and developed gangrenous toes.