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.
Background: Given that excess opioid prescriptions contribute to the United States opioid epidemic and there are few national opioid prescribing guidelines for the management of acute pain, it is pertinent to determine if prescribers can sufficiently assess their own prescribing practice. The purpose of this study was to investigate podiatric surgeons’ ability to evaluate if their own opioid prescribing practice is less than, near, or above that of an “average” prescriber.
Methods: We administered a scenario-based, voluntary, anonymous, online questionnaire via Qualtrics which consisted of five surgery-based scenarios commonly performed by podiatric surgeons. Respondents were asked the quantity of opioids they would prescribe at the time of surgery. Respondents were also asked to rate their prescribing practice compared to the average (median) podiatric surgeons. We compared self-reported behavior to self-reported perception (“I prescribe less than average,” “I prescribed about average,” and “I prescribe more than average”). ANOVA was used for univariate analysis between the three groups. We used linear regression to adjust for confounders. Data restriction was used to account for restrictive state laws.
Results: One hundred fifteen podiatric surgeons completed the survey from in April 2020. Less than half of the time, respondents accurately identified their own category. Consequently, there were no statistically significant differences between podiatric surgeons who reported that they “prescribe less,” “prescribe about average,” and “prescribe more.” Paradoxically, there was a flip in scenario #5, whereas respondents who reported they “prescribe more” actually prescribed the least and respondents who believed that they “prescribe less” actually prescribed the most.
Conclusions: Cognitive bias, in the form of a novel effect, occurs in postoperative opioid prescribing practice; in the absence of procedure-specific guidelines or an objective standard, podiatric surgeons, more often than not, were unaware of how their own opioid prescribing practice measured up to other podiatric surgeons.
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)
There is a need for postoperative pain control that minimizes or eliminates opioid use during the first 72 hours following surgery, when pain is most severe. HTX-011 is an extended-release, dual-acting local anesthetic that demonstrated superior 72-hour analgesia over standard of care bupivacaine hydrochloride (HCl) and saline placebo in a phase 3 bunionectomy study (EPOCH-1). Having shown HTX-011 monotherapy is superior to bupivacaine HCl in reducing postoperative pain intensity and opioid use, this follow-on study evaluated the safety and efficacy of HTX-011 as the foundation of a multimodal analgesia (MMA) regimen using over-the-counter medications recommended by practice guidelines for pain management.
Following regional anesthesia administered as a lidocaine block, patients underwent unilateral bunionectomy with osteotomy and internal fixation. Prior to closure, HTX-011 (up to 60 mg bupivacaine/1.8 mg meloxicam) was applied without a needle. Patients received scheduled postoperative MMA alternating ibuprofen (600 mg) and acetaminophen (1 g) every 3 hours for 72 hours. Efficacy was assessed based on pain intensity (numeric rating scale [NRS; 0–10]) and consumption of opioid rescue medication (intravenous morphine milligram equivalents [MME]). Adverse event and vital sign monitoring, plus laboratory and wound healing assessments, were used to determine safety.
Over the 72-hour assessment period following bunionectomy, mean pain scores were mild in severity (NRS <4) and 22/31 patients (71%) experienced no severe pain (NRS ≥7) with HTX-011 as the foundation of scheduled, non-opioid MMA. Patients consumed an average of 1.61 MME total, with 24/31 (77%) requiring no opioid rescue medication (opioid-free). HTX-011 was well-tolerated and demonstrated no safety concerns with the inclusion of postoperative MMA.
HTX-011 as the foundation of an MMA regimen including scheduled ibuprofen and acetaminophen maintained mean postoperative pain scores in the mild range and enabled opioid-free recovery for 77% of bunionectomy patients through the 28-day recovery period.
Analgesic medications are distributed to a variety of receptors within the central nervous system. Activity at these receptors (mu 1, mu, sigma, delta, kappa) results in both the beneficial pain-relieving effects of analgesics as well as undesirable side effects. The mixed agonist-antagonist class of analgesics offers the potential benefit of greater receptor site selectivity while diminishing the incidence of adverse sequelae, such as respiratory depression. Traditionally, it has been suggested that mixed agonist-antagonist medications may be associated with decreased analgesic effectiveness. However, newer agents of this mixed class may result in effective analgesia while diminishing the incidence of side effects.
Foot pain, if not effectively managed, can result in significant disability and loss of function in older patients. This article reviews treatment strategies for acute and persistent pain, emphasizing new pharmacologic approaches. Indications, guidelines, and precautions for acute-pain treatment with acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, and opioids are discussed. Strategies for management of persistent pain using opioids, tricyclic antidepressants, gabapentin, and topical medications are reviewed. Common pain-management and prescribing errors are highlighted. (J Am Podiatr Med Assoc 94(2): 98-103, 2004)
The opioid epidemic has hit disastrous levels across the United States. Many attempts have been made to counteract this, including policy changes and modification of provider and patient behavior. The purpose of this study was to understand the current state of podiatric residents' knowledge regarding pain management and addiction.
This study used mixed quantitative-qualitative methods. Two focus groups were conducted with two podiatric residency programs to understand current issues and inform the creation of a survey. A 30-question survey was created and peer reviewed to assess general pain management knowledge, levels of confidence in pain management and addiction, and areas for improvement.
Pain management education in podiatry is mainly focused on opioids. These concepts are often taught in a nonstandardized method, which does not often include nonopioid alternatives. Knowledge of risk factors for addiction was lacking, whereas knowledge of behaviors concerning for addiction was more bountiful. Thirty-three surveys were completed of a possible 39. A knowledge score was created from eight survey questions for a total of 10 points, with an average score of 4.61. There was no statistical difference between those with and without a pain management rotation. Nearly all residents felt comfortable managing surgical pain. The residents are “never” or “only occasionally” inquiring about risk factors for addiction. Questions asked also suggest that the residents are not thinking about their role within the opioid epidemic.
As the opioid epidemic grows, it is imperative to examine the causes and solutions to the problem. Focusing efforts on educating resident physicians is one method to address the issue. The results of this study show that pain management basics need to be reinforced and more time must be spent emphasizing the importance of thorough patient histories and educating patients when prescribing pain medication.
The appropriate treatment for postoperative pain remains a common dilemma for podiatric surgeons and patients undergoing surgery of the foot and ankle. The treatment of moderate to severe acute pain typically relies heavily on the use of opioid analgesics, such as hydrocodone and oxycodone, which are often associated with adverse effects, including nausea and vomiting. These adverse effects may have a negative impact on postoperative outcomes and reduce patient compliance with analgesic therapy. Tapentadol is a novel, centrally acting analgesic with two mechanisms of action—μ-opioid receptor agonism and norepinephrine reuptake inhibition—in a single molecule. Tapentadol immediate release has been evaluated in a series of clinical trials in patients with postoperative pain after bunionectomy. The results of these studies demonstrate that tapentadol immediate release is associated with an improved gastrointestinal tolerability profile relative to oxycodone immediate release at doses providing comparable analgesia. Therefore, tapentadol immediate release may offer an improved analgesic option for the relief of postoperative pain after podiatric surgery. (J Am Podiatr Med Assoc 102(2): 139–148, 2012)
Two randomized, double-blind, placebo-controlled studies assessed the analgesic efficacy of valdecoxib in patients with moderate-to-severe pain after bunionectomy. Study 1 (N = 374) assessed the efficacy of two regimens of valdecoxib on the day after surgery (valdecoxib, 40 mg, with a 20-mg redose [n = 127]; valdecoxib, 40 mg, with a placebo redose [n = 122]; and placebo/placebo [n = 125]), and study 2 (N = 478) examined the efficacy of two different multiple-dose regimens on postoperative days 2 through 5 (valdecoxib, 20 mg, twice daily [n = 160]; valdecoxib, 20 mg, once daily [n = 159]; and placebo [n = 159]). Valdecoxib provided significant pain relief and reduced the use of opioid rescue medication. This efficacy was accompanied by improved global scores, decreased pain interference with function, and increased patient satisfaction. (J Am Podiatr Med Assoc 96(5): 393–407, 2006)
Recently, transcranial direct current stimulation (tDCS), a noninvasive brain stimulation technique, was proposed as a suitable method for the treatment of several chronic pain syndromes. We describe a case of severe heel pain in a diabetic patient with plantar fasciitis successfully treated with tDCS.
The present study investigated whether tDCS treatment could reduce pain and pain-related anxiety in a 65-year-old diabetic man affected by treatment-resistant right heel pain due to plantar fasciitis. The patient underwent five tDCS treatment sessions on 5 consecutive days. Each session consisted of 20-min anodal tDCS over the left primary motor cortex leg area.
The neurostimulation protocol induced a decrease in pain intensity and pain-related anxiety that outlasted the stimulation (1 week). Furthermore, the patient stopped the intake of opioid medication.
Therapeutic neuromodulation with tDCS may represent an alternative option for treating severe lower-extremity pain.