Background: Surgery is a common setting for opioid-naive patients to first be exposed to opioids. Understanding the multimodal analgesic-prescribing habits of podiatric surgeons in the United States may be helpful to refining prescribing protocols. The purpose of this benchmark study was to identify whether certain demographic characteristics of podiatric surgeons were associated with their postoperative multimodal analgesic-prescribing practices.
Methods: We administered a scenario-based, voluntary, anonymous, online questionnaire that consisted of patient scenarios with a unique podiatric surgery followed by a demographics section. We developed multiple logistic regression models to identify associations between prescriber characteristics and the odds of supplementing with a nonsteroidal anti-inflammatory drug, regional nerve block, and anticonvulsant agent for each scenario. We developed multiple linear regression models to identify the association of multimodal analgesic-prescribing habits and the opioid dosage units prescribed at the time of surgery.
Results: Eight hundred sixty podiatric surgeons completed the survey. Years in practice was a statistically significant variable in multiple scenarios. Compared with those in practice for more than 15 years, podiatric surgeons in practice 5 years or less had increased odds of reporting supplementation with an anticonvulsant agent in scenarios 1 (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.11–5.18; P = .03), 3 (OR, 2.97; 95% CI, 1.55–5.68; P = .001), 4 (OR, 2.54; 95% CI, 1.56–4.12; P < .001), and 5 (OR, 2.07; 95% CI, 1.29–3.32; P = .003).
Conclusions: Podiatric surgeons with fewer years in practice had increased odds of supplementing with an anticonvulsant. Approximately one-third of podiatric surgeons reported using some form of a nonopioid analgesic and an opioid in every scenario. The use of multimodal analgesics was associated with a reduction in the number of opioid dosage units prescribed at the time of surgery and may be a reasonable adjunct to current protocols.
There is increased recognition that governmental agencies, patients, pharmaceutical companies, and clinicians all contribute to the US opioid epidemic.1–5 These same parties can make meaningful contributions to resolve the epidemic by identifying ineffective habits and encouraging change.1–3 Surgery is a common setting for opioid-naive people to first be exposed to opioids.6 From July 2016 to June 2017, surgeons prescribed more than 10.8% of the 209.5 million opioid prescriptions in the United States.7 Musculoskeletal surgeons in particular have been targeted as major contributors to opioid prescribing due to these procedures being associated with often severe levels of postoperative pain.8 Not surprisingly, musculoskeletal surgeons have been reported to be responsible for more than half of the prescriptions given by all surgeons.7 Recent efforts have been made to establish guidelines for surgeons regarding opioid dispensing for common surgical procedures, and shifting toward a multimodal analgesic approach when possible.6,8 The use of multimodal analgesics can reduce the need for opioid consumption during the postoperative period.8–10 In addition, a multimodal analgesic approach can produce superior analgesia over an opioid-only approach by targeting a variety of pain pathways.8,9,11–14
Understanding the multimodal analgesic-prescribing habits of podiatric surgeons in the United States may be helpful to refining prescribing protocols with the aim of effectively controlling postoperative pain and minimizing unused opioid distribution after foot and ankle surgery.14,16 The purpose of this study was to evaluate the current hypothetical use of multimodal analgesic approaches for postoperative pain management among podiatric surgeons. We believe that there will be a variation in postoperative protocols based on previous work, where less experienced foot and ankle surgeons will have higher odds of supplementing postoperative opioids with nonopioid analgesics compared with more experienced surgeons (in practice >15 years).1,17 In addition, we aimed to identify whether certain demographic characteristics of podiatric surgeons were associated with their postoperative multimodal analgesic-prescribing practices.
Methods
Research Design
This study was based on a previously published survey by Hearty et al17 in 2018 consisting of four rearfoot and ankle scenarios and 31 questions and described the prescribing habits of orthopedic foot and ankle surgeons. The data from the present study were originally part of a larger study by Brooks et al,1 but it was not previously published; a decision a posteriori to break up the original study into multiple studies was made by the authors given the relatively large size of the data and the admittedly ambitious scope of the original study. We received exempt status from the Committee for the Protection of Human Subjects at Dartmouth College (Hanover, New Hampshire) and the institutional review board at the Rosalind Franklin University of Medicine and Science (North Chicago, Illinois) for an open, voluntary, anonymous, online questionnaire distributed on the Internet via Qualtrics, an online survey platform that uses panel-based sampling to reach specific demographic groups (Qualtrics, Seattle, Washington). No personal or identifiable information was stored. Respondents received no incentive for survey completion, and they could use a back button to revisit their answers. We modified and improved on the previous survey by Hearty et al17 by including additional questions, an in-office procedure scenario, and a forefoot surgery scenario (Appendix 1). Additional questions included data regarding opioid choice and number of “pills” (dosage units) dispensed for the purpose of reporting prescribing habits, as well as additional questions regarding prescriber characteristics. Given the nature of the in-office procedure scenario, we made an a posteriori decision to report it in a separate study; consequently, we renumbered the scenarios reported in this study. Content validity was established through an extensive review of the literature in September 2018 and by the members of the 2019–2020 Clinical Practice Advisory Committee of the American Podiatric Medical Association (APMA), who served as content experts and offered input on each patient scenario and on commonly prescribed postoperative pain medications in foot and ankle surgery. We completed the pilot study in October 2019. This study adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), found in Appendix 2.
Sample and Population
The target population was practicing podiatric surgeons in the United States. We recruited practicing podiatric surgeons exclusively through e-mail invitation from the APMA membership list, which consisted of approximately 8,736 members who fit the eligibility criteria. Retired podiatric surgeons, podiatric physicians who no longer perform surgery, current fellows, and residents were excluded. Survey respondents who did not complete the demographics section, which was at the end of the questionnaire, were also excluded from the analysis.
The Survey
Eight survey invitations were sent via e-mail from December 10, 2019, to April 10, 2020. In the consent statement provided at the beginning of the survey, participants were asked to respond to the questionnaire only once. The survey took an estimated 10 to 15 min to complete. Respondents were presented with five different scenarios. For each scenario, respondents were then provided six multiple-choice options regarding which postoperative medication they would prescribe. Respondents were also provided multiple-choice responses for the common schedules and doses of the prescribed medication and asked to complete a fill-in-the-blank response for the number of “pills” (dosage units) prescribed at the time of surgery. Dichotomous options for supplementing with a nonsteroidal anti-inflammatory drug (NSAID), regional nerve block, and anticonvulsant agent were provided. We collected the following demographic information: gender identity, years in practice, podiatric medical school, years of residency, completion of a fellowship, practice setting, and the US state in which each respondent primarily practiced. States were then reclassified into the US Census regions (Midwest, Northeast, South, and West), with Puerto Rico classified in the South region.
Variables of Interest
There were four dependent variables: three (supplementation with an NSAID, use of a regional nerve block, and supplementation with an anticonvulsant agent) were dichotomous and one (opioid dosage units prescribed at the time of surgery) was continuous. An a priori decision was made to exclude podiatric surgeons who opted to prescribe nonopioids at the time of surgery from the analysis. The most common (mode) opioid prescribed overall was also reported.
Statistical Analysis
Unweighted responses were analyzed. Linear and multiple logistic regression models were used to understand the strength and direction of the association between the outcome variables and independent variables. All of the assumptions were tested and met. We analyzed the data using R v4.0.3 (The R Foundation, Boston, Massachusetts). A predefined alpha level of 0.05 or less was used for statistical significance, and only completed surveys were analyzed.
Results
Descriptive Results
The survey included 860 podiatric surgeons, which resulted in a completeness rate of 86% and a response rate of 9.8% (Fig. 1), or approximately 5% of the total practicing podiatric physicians in the United States. Approximately 11% of respondents completed a 1- to 2-year fellowship program after residency. The most commonly prescribed opioid in scenarios 1 through 3 was hydrocodone, and oxycodone was more commonly prescribed in scenarios 4 and 5. Thirty-one percent of podiatric surgeons reported that they would use a multimodal approach in their postoperative protocols for all five scenarios (Table 1). A breakdown of the percentage of multimodal analgesics given by respondents who opted for a multimodal analgesic approach is given in Table 2; regional nerve blocks were the most common nonopioid analgesics used by podiatric surgeons across all scenarios.
Representation of response rate and completeness rate.
Citation: Journal of the American Podiatric Medical Association 113, 4; 10.7547/21-145
Postoperative Pain Management Approach Used by Opioid Prescribers for Each Scenario
Analgesics Given by Respondents Who Reported Using a Multimodal Approach
Statistical Analysis
The collective results from the statistical analyses appear in Tables 3 and 4. Individual scenario results also appear below.
Adjusted Logistic Regression Models for Supplementing with a Nonopioid (Regional Nerve Block, NSAID, Anticonvulsant) Among Opioid Prescribers
Adjusted Linear Regression Model for Opioid Dosage Units Prescribed at the Time of Surgery
Scenario 1: First Metatarsal Osteotomy (Austin Bunionectomy).
Female sex was associated with a decreased likelihood (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.22–0.90; P = .02) of supplementing with an anticonvulsant agent. Compared with practicing for greater than 15 years, practicing for 5 years or less (OR, 2.4; 95% CI, 1.11–5.18; P = .03) and practicing for 6 to 15 years (OR, 2.54; 95% CI, 1.32–4.85; P = .005) were associated with increases in the odds of supplementing with an anticonvulsant agent.
Scenario 2: Open Brostrom-Gould Repair.
Compared with practicing for greater than 15 years, practicing for 5 years or less (OR, 3.12; 95% CI, 1.47–6.62; P = .003) and practicing for 6 to 15 years (OR, 1.79; 95% CI, 1.06–3.04; P = .031) were associated with increases in the odds of supplementing with a regional nerve block. Completing a fellowship (OR, 0.49; 95% CI, 0.28–0.87; P = .015) was associated with decreased odds of supplementing with a regional nerve block.
Female sex (OR, 1.76; 95% CI, 1.13–2.74; P = .01) was associated with an increase in the odds of supplementing with an NSAID. Compared with practicing for greater than 15 years, practicing for 6 to 15 years (OR, 2.48; 95% CI, 1.31–4.70; P = .005) was associated with an increase in the odds of supplementing with an anticonvulsant agent. Compared with affiliation with a private practice, affiliation with a federal health system (OR, 3.03; 95% CI, 1.17–7.83; P = .02) was associated with an increase in the odds of supplementing with an anticonvulsant agent. Completing a fellowship (estimate, 3.82; 95% CI, 1.61–6.04; P = .001), practicing for 5 years or less (estimate, 3.34; 95% CI, 1.27–5.42; P = .002), and practicing for 6 to 15 years (estimate, 4.44; 95% CI, 2.67–6.21; P < .001) were associated with an increase in the number of opioid dosage units prescribed at the time of surgery. Supplementing with an NSAID (estimate, –2.46; 95% CI, –3.92 to –0.99; P = .001) was associated with a decrease in the number of opioid dosage units prescribed.
Scenario 3: Open Reduction and Internal Fixation of a Closed Bimalleolar Ankle Fracture.
Female sex (OR, 2.95; 95% CI, 1.67–5.22; P < .001) and practicing for 6 to 15 years (OR, 2.94; 95% CI, 1.65–5.22; P < .001) were associated with an increase in the odds of using a regional nerve block.
Compared with practicing for greater than 15 years, practicing for 5 years or less (OR, 2.97; 95% CI, 1.55–5.68; P = .001) and for 6 to 15 years (OR, 2.34; 95% CI, 1.32–4.15; P = .004) were associated with an increase in the odds of supplementing with an anticonvulsant agent. Compared with those affiliated with a private practice, being affiliated with a hospital/health system (OR, 1.98; 95% CI, 1.03–3.81; P = .04) was associated with an increase in the odds of supplementing with an anticonvulsant agent. Completing a fellowship (estimate, 3.58; 95% CI, 1.43–5.72; P = .001), practicing for 5 years or less (estimate, 3.06; 95% CI, 0.92–5.20; P = .005), and practicing for 6 to 15 years (estimate, 4.44; 95% CI, 2.68–6.19; P < .001) were associated with an increase in the number of opioid dosage units prescribed at the time of surgery.
Scenario 4: Tibiotalocalcaneal Arthrodesis with Tendo Achilles Lengthening.
Female sex (OR, 1.9; 95% CI, 1.16–3.12; P = .011), practicing for 6 to 15 years (OR, 4.23; 95% CI, 2.35–7.62; P < .001), and working in a hospital/health system (OR, 2.18; 95% CI, 1.02–4.64; P = .04) were associated with an increase in the odds of supplementing with a regional nerve block. Compared with living in the Midwest, living in the South (OR, 0.56; 95% CI, 0.37–0.85; P = .007) was associated with a decrease in the odds of supplementing with an NSAID. Practicing for 5 years or less (OR, 2.54; 95% CI, 1.56–4.12; P < .001) and working for a hospital/health system (OR, 1.76; 95% CI, 1.04–2.96; P = .034) were associated with an increase in the odds of supplementing with an anticonvulsant agent. Supplementing with a nerve block (estimate, –3.66; 95% CI, –7.01 to –0.30; P = .033) and supplementing with an NSAID (estimate, –3.58; 95% CI, –6.51 to –0.65; P = .017) were associated with decreases in opioid dosage units prescribed at the time of surgery.
Scenario 5: Total Ankle Arthroplasty with Tendo Achilles Lengthening.
Female sex (OR, 2.82; 95% CI, 1.54–5.15; P = .001) and working for a hospital/health system (OR, 2.99; 95% CI, 1.20–7.42; P = .018) were associated with an increase in the odds of supplementing with a regional nerve block. Compared with being in a private practice, working for a hospital/health system (OR, 1.89; 95% CI, 1.03–3.47; P = .041) was associated with an increase in the odds of supplementing with an NSAID. Compared with practicing for greater than 15 years, practicing for 5 years or less (OR, 2.07; 95% CI, 1.29–3.32; P = .003) was associated with an increase in the odds of supplementing with an anticonvulsant agent. Practicing for 6 to 15 years (estimate, 2.47; 95% CI, 0.32–4.61; P = .024) was associated with an increase in opioid dosage units prescribed. Supplementing with an NSAID (estimate, –1.83; 95% CI, –3.50 to –0.16; P = .032) was associated with a decrease in opioid dosage units prescribed at the time of surgery. Completing a fellowship (estimate, 2.54; 95% CI, 0.99–6.65; P = .038) and practicing for 6 to 15 years (estimate, 2.54; 95% CI, 0.15–4.94; P = .038) were associated with an increase in opioid dosage units prescribed.
Discussion
In this national cross-sectional study of 860 podiatric surgeons, approximately 82% of podiatric surgeons used some form of a multimodal postoperative protocol. Regional nerve blocks were the most common nonopioid form of analgesia given by respondents, followed by NSAIDs, and then anticonvulsant agents (Table 2). Across multiple scenarios, the use of multimodal analgesics resulted in fewer opioids being dispensed postoperatively; however, statistical significance was achieved only four times (in three of the five scenarios). The use of NSAIDs was associated with significantly fewer opioids being prescribed at the time of surgery three of the aforementioned four times (Table 4). Use of an NSAID was reported highest in the sole nonosseous surgery (scenario 2). Although NSAID use has led to bone-healing complications in animal models and in vitro studies, Hassan and Karlock17 demonstrated, in a retrospective cohort study, that short-term postoperative NSAID use had no statistically significant difference in osseous nonunion outcomes in elective foot and ankle surgery.
Proper postoperative pain management considers a patient’s opioid history. In this present study, the two scenarios that included non–opioid-naive patients (scenarios 4 and 5) saw an increase in supplementing with an anticonvulsant agent (ie, gabapentin, pregabalin) while simultaneously seeing a decrease in NSAIDs prescribed (Table 2). Note that anticonvulsant agents are not without an addiction risk of their own.18 The principal population at risk for addiction consists of patients with other current or past substance use disorders, mostly opioid and multidrug users.18 Pregabalin seems to be somewhat more addictive than gabapentin.18 Overdoses of these drugs can become lethal in mixture with opioids and sedatives.18 Bonnet and Scherbaum18 recommended that in patients with a history of substance use disorders, gabapentin and pregabalin should be avoided or, if indispensable, administered with caution by using strict therapeutic and prescription monitoring.
Prescribing protocols in foot and ankle surgery should aim to effectively control postoperative pain and minimize unused opioid distribution. Potentially reducing the length of stay in a hospital is another benefit. Although it is well-known that multimodal analgesics can help achieve these goals,8,9 the mere use of any multimodal approach does not guarantee improved outcomes.19 In a prospective, double-blind, randomized controlled trial, Hancock et al19 examined the efficacy of analgesic injections in closed rotational ankle fractures that were treated operatively. The injection group was noted to have lower mean pain scores for the first 24 and 48 hours; however, there was no significant reduction in opioid consumption, meaningful reduction in pain levels, or length of stay in the hospital.19 Although not a direct comparison, in the present study, regional nerve blocks and NSAIDs were associated in a reduction of opioid dosage units prescribed at the time of surgery in the open reduction and internal fixation of a closed bimalleolar ankle fracture scenario (scenario 3). Furthermore, in a retrospective study, Michelson et al20 noted favorable outcomes with a pain protocol for patients who underwent foot and ankle surgery by using a preoperative multimodal regimen of an opioid, an NSAID, an anticonvulsant agent, acetaminophen, and prednisone followed by a postoperative regimen of opioids, NSAIDs, and acetaminophen.20,21 Patients who received the aforementioned multimodal analgesic protocol did, unlike in the study by Hancock et al,19 have a shorter length of stay regardless of the complexity of the foot and ankle surgery.20,21
The present study expanded on previous work by Hearty et al.17 Hearty et al’s questionnaire-based cross-sectional study (n = 64) examined the association between prescriber characteristics and postoperative pain management prescribing practice among orthopedic foot and ankle surgeons. Hearty et al17 demonstrated that less experienced orthopedic surgeons tended to supplement with regional nerve blocks more than experienced surgeons. In the present study, less experienced podiatric surgeons (ie, those in practice ≤5 years and 6–15 years) were more likely to supplement their postoperative opioid prescriptions with an NSAID, regional nerve block, or anticonvulsant agent in multiple scenarios. This similarity between less experienced orthopedic and podiatric surgeons may highlight another area of needed education for foot and ankle surgeons based on their years in practice.
This study has several limitations. We presented hypothetical situations and asked podiatric surgeons what they would expect to prescribe for each scenario. As such, we did not obtain data regarding actual prescribing habits, and there may be variation between what prescribers say they will prescribe versus what they actually prescribe. In addition, the use of acetaminophen, cannabidiol, and other analgesics was not included in or captured by this study. Although the APMA is a large organization, its membership may not accurately serve as a proxy for the entire podiatric surgeon population in the United States; thousands of podiatric surgeons are not members of the APMA. Furthermore, this study had a 9.8% response rate (n = 860), which is an improvement on previous research with much lower sample sizes; however, low overall response rates make it difficult to generalize findings to all podiatric surgeons practicing in the United States.
Conclusions
Postoperative multimodal analgesic-prescribing practice variation exists in foot and ankle surgery. Podiatric surgeons with fewer years in practice had increased odds of supplementing with an anticonvulsant agent. One-third of all podiatric surgeons reported that they would use an NSAID, a regional nerve block, and/or an anticonvulsant agent as well as an opioid for postoperative pain management for all foot and ankle surgeries. The use of multimodal analgesics tended to be associated with reductions in the number of opioid dosage units prescribed at the time of surgery and may be a reasonable adjunct to current protocols. Hydrocodone was the most common opioid of choice prescribed by podiatric surgeons for opioid-naive patients; for non–opioid-naive patients, oxycodone surpassed hydrocodone as the opioid of choice. Regardless of the foot and ankle surgery, regional nerve blocks were the most common nonopioid analgesic used by podiatric surgeons. Further research is needed to determine the impact of a multimodal analgesic approach on opioid prescribing and consumption in a prospective cohort of patients after foot and ankle surgery.
Acknowledgment: This study served as the primary author’s capstone project for his coursework at the Geisel School of Medicine/The Dartmouth Institute (2019-2022); consequently, the primary author would like to thank the faculty, staff, and his fellow classmates at The Dartmouth Institute for their feedback. All authors acknowledge and thank the members of the Clinical Practice Advisory Committee of the American Podiatric Medical Association for their role as content experts.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
References
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Appendix 1. Patient Scenarios
Scenario 1 Procedure: First Metatarsal Osteotomy (Austin Bunionectomy)
“[A] 45-year-old woman has worsening bunion pain and can no longer tolerate her usual shoes; otherwise healthy. Conservative care has not been successful. She takes ibuprofen as needed for the pain and has never taken opioid pain medication. Radiographs reveal an intermetatarsal angle of 13°.”
Scenario 2 Procedure: Open Brostrom-Gould Repair
“[A] 20-year-old man has lateral ankle instability after sustaining multiple ankle sprains; otherwise healthy. He is a manual laborer. He takes ibuprofen as needed for the pain and has never taken opioid pain medication.”
Scenario 3 Procedure: Open Reduction and Internal Fixation of a Closed Bimalleolar Ankle Fracture
“[A] 45-year-old woman; BMI 35; otherwise healthy; bimalleolar closed ankle fracture from slip and fall. She has no previous history of ankle/foot problems. The patient is a stay-at-home mother. She has been taking 2-3 tablets per day of 5 mg hydrocodone since her injury.”
Scenario 4 Procedure: Tibiotalocalcaneal Arthrodesis with Tendo Achilles Lengthening
“[A] 65-year-old man, insulin-dependent diabetic, BMI 40, has Charcot arthropathy of the foot and ankle and significant deformity. He has altered but intact sensation. He has a history of low back pain and takes daily acetaminophen and occasional hydrocodone.”
Scenario 5 Procedure: Total Ankle Arthroplasty with Tendo Achilles Lengthening
“[A] 59-year-old woman with post-traumatic ankle arthritis. She has a history of fibromyalgia and chronic pain. She has been on hydrocodone 5 mg, two to three tablets per day for more than 2 years as well as an antidepressant medication. She is under the care of a chronic pain physician, who refuses to make recommendations on a postoperative pain medication plan. She is otherwise healthy.”
Appendix 2. Checklist for Reporting Results of Internet E-Surveys (CHERRIES)
