Background: More than half of opioid misusers last obtained opioids from a friend or relative, a problematic reflection of the commonly known opioid reservoir maintained by variable prescription rates and, notably, excessive postoperative prescription. We examined the postoperative opioid-prescribing approaches among podiatric physicians.
Methods: We administered a scenario-based, anonymous, online questionnaire via an online survey platform. The questionnaire consisted of five patient–foot surgery scenarios aimed at discerning opioid-prescribing approaches. Respondents were asked how many opioid “pills” (dosage units) that they would prescribe at the time of surgery. We divided respondents into two opioid-prescribing approach groups: one-size-fits-all (prescribed the same dosage units regardless of the scenario) and patient-centric and procedure-focused (prescribed varied amounts of opioid dosage units based on the patient’s opioid history and the procedure provided in each scenario). We used the Mann-Whitney U test to determine the difference between the opioid dosage units prescribed at the time of surgery by the two groups.
Results: Approximately half of the respondents used a one-size-fits-all postoperative opioid-prescribing approach. Podiatric physicians who used a patient-centric and procedure-focused approach reported prescribing significantly fewer opioid dosage units in scenarios 1 (partial toe amputation; –9.1; P = .0087) and 2 (incision and drainage with partial fifth-ray resection; –12.3; P = .0024), which represented minor procedures with opioid-naive patients.
Conclusions: Podiatric physicians who used a one-size-fits-all opioid-prescribing approach prescribed more postoperative opioid dosage units regardless of the scenario. Given that the patient population requiring foot surgery is diverse and may have multiple comorbidities, the management of postoperative pain, likewise, should be diverse and nuanced. The patient-centric and procedure-focused approach is suited to limit excess prescribing while defending the physician-patient relationship.
The US opioid epidemic has substantially worsened during the COVID-19 pandemic.1 The Centers for Disease Control and Prevention estimates that more than 100,000 Americans have died of overdoses during the first 12 months of the COVID-19 pandemic following lockdowns.1 It is estimated that at least 75% of these overdose deaths were from opioids.1 Overdose deaths are up 28.5% from the previous 12 months.1 Among the many things that the COVID-19 pandemic has demonstrated is the need for large-scale cooperation to solve complex issues with willing buy-in from stakeholders.2
Excess prescribing of opioids has contributed to the US opioid epidemic.3–5 More than half of opioid misusers last obtained opioids from a friend or relative, a problematic reflection of the commonly known opioid reservoir, which results from excess prescribing.6–9 Changes to state laws since 2016 have produced mixed results in reducing excess opioid prescribing for acute pain.10,11 Brooks et al were the first to demonstrate that significant opioid-prescribing variation exists on the national level among podiatric physicians at the National Scientific Conference of the American Podiatric Medical Association (APMA) in 2020.10,11 Given that clinically meaningful postoperative opioid-prescribing variation exists among podiatric physicians,13 it is pertinent to further understand the underlying origin of these prescribing habits.
We aimed to determine whether differences in postoperative opioid-prescribing practice exist among two different prescribing approaches: one-size-fits-all and patient-centric and procedure-focused. The one-size-fits-all approach represents podiatric physicians who prescribe the same quantity of opioids at the time of surgery regardless of the patient and procedure, whereas the patient-centric and procedure-focused approach results in varying quantities of opioids prescribed at the time of surgery by podiatric physicians. We hypothesize that podiatric physicians who use the patient-centric and procedure-focused approach prescribe fewer postoperative opioids at the time of surgery compared with those who subscribe to the one-size-fits-all prescribing approach.
Methods
Research Design
Content validity was established through an exhaustive review of the literature in September 2019 and by the members of the 2019–2020 Clinical Practice Advisory Committee of the APMA, who functioned as content experts. We received institutional review board exempt status from the Committee for the Protection of Human Subjects at Dartmouth College (Hanover, New Hampshire) for an open, voluntary, anonymous, five-scenario, online questionnaire distributed on the Internet via Qualtrics, an online survey platform (Qualtrics, Seattle, Washington). Respondents received no incentive for survey completion, and they could use a back button to revisit their answers. No personal or identifiable information was stored. We completed the pilot study in March 2020. We decided a posteriori to break the original study into separate publications and subsequently received institutional review board modification approval to do so. This study followed the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), which is listed in Appendix 1.
Questionnaire and Sample
The survey took an estimated 10 to 15 min to complete. There were 120 questions in the survey; however, we used conditional branching so that each respondent who elected to prescribe only one opioid per scenario would have no more than 60 questions appear. There were never more than seven questions per page. Respondents were presented with five different scenarios (Appendix 2), each with a varied opioid history (ie, opioid naive, off-and-on opioid user, and daily user for chronic pain/opioid tolerant) and a unique foot surgery (ie, soft tissue, osseous). For each scenario, respondents were asked to complete a fill-in-the-blank response for the number of opioid “pills” (dosage units) prescribed at the time of surgery. Respondents who reported that they prescribe the same quantity of dosage units regardless of the scenario were classified as the one-size-fits-all approach group. Respondents who reported varied quantities of dosage units based on the scenario were classified as the patient-centric and procedure-focused approach group. Survey respondents who did not complete the demographics section or respond to at least two scenarios were also excluded from analysis. We excluded respondents who provided information for only one scenario because they could not be classified in either approach group.
The target population was practicing podiatric physicians in the United States. We recruited practicing podiatric physicians by way of e-mail invitation from the APMA, which consisted of approximately 8,736 members who fit the eligibility criteria. Retired podiatric physicians, podiatrists who no longer perform surgery, current fellows, and residents were excluded. An a priori decision was made to exclude respondents from states with restrictive laws for acute pain, which we defined as less than 7 days of postoperative opioids being the limit. Florida, which has a more complex law with a 3-day maximum that can be extended to 7 days, was also excluded. States with laws of 7 days or more or no laws were included in the analysis. Two survey invitations were sent out via e-mail to practicing APMA members during the data collection period (March 20, 2020, to April 20, 2020). The consent statement (Appendix 3), which was provided at the beginning of the survey, asked participants to respond to the questionnaire only once.
Statistical Analysis
Completed surveys were analyzed at a predefined alpha level of 0.05 or less for statistical significance. Unweighted responses were analyzed. We analyzed the data using R v4.0.3 (The R Foundation, Boston, Massachusetts). The Mann-Whitney U test was used to determine whether a difference exists between the two aforementioned approaches. Opioid “pills” (dosage units) prescribed at the time of surgery was the outcome variable.
Results
Descriptive Results
One hundred fifteen podiatric physicians completed the demographics section at the end of the survey, resulting in an overall response rate of 1.32% (115 of 8,736). The survey was sent to 8,736 APMA members who met the inclusion criteria. There was a completeness (made it to the end) rate of 89.84% (115 of 128); however, not all respondents answered the amount of opioid dosage units prescribed for each scenario. Of note, by decision a priori, respondents were not removed from the analysis if they responded to at least two of the five scenarios; however, this led to the number of opioids prescribed by the one-size-fits-all approach to be different in each scenario (ie, a respondent might have prescribed the same in four scenarios and skipped one because they do not regularly perform that surgery). Consequently, the sample size for each scenario varied slightly. Approximately 49% of respondents, which was the average across all scenarios, used the one-size-fits-all postoperative opioid-prescribing approach, and 51% of respondents used the patient-centric and procedure-focused approach.
Mann-Whitney U Test
Scenario 1 (P = .0087) and scenario 2 (P = .0024) were significant. Scenario 3 (P = .0747), scenario 4 (P = .5604), and scenario 5 (P = .2727) were not significant (Table 1). The full scenarios are listed in Appendix 2. Podiatric physicians who used the patient-centric and procedure-focused approach reported prescribing less in scenarios 1 (–9.1), 2 (–12.3), 3 (–8.2), 4 (–2.7), and 5 (–4.5) compared with podiatric physicians who used a one-size-fits-all prescribing approach.
Postoperative Opioid Reduction with the Patient-Centric and Procedure-Focused Approach Compared with the One-Size-Fits-All Approach via Mann-Whitney-Wilcoxon Test Results by Scenario
Discussion
In this questionnaire-based, cross-sectional study of 115 podiatric physicians, most respondents self-reported their use of a patient-centric and procedure-focused approach for postoperative opioid prescribing. Those who used this approach reported prescribing significantly fewer opioids compared with those who self-reported a one-size-fits-all approach for minor procedures with opioid-naive patients (scenarios 1 and 2); the difference between prescribing approaches for the minor procedures was approximately nine to 13 fewer opioid dosage units prescribed at the time of surgery. We believe this to be clinically meaningful as we established 8 opioid dosage units a priori as clinically meaningful. A reduction of eight opioids per prescription would reduce the opioid reservoir that has led to many Americans’ misuse and abuse of prescription opioids.6–8,15 To reduce the opioid reservoir, several different approaches have been described in the literature.16,17
Several strategies have been suggested or developed to help mitigate the US opioid epidemic.18 Robert Smith, a podiatric physician, outlined the need for an interprofessional team approach18; furthermore, he advocated for the utilization of opioid stewardship programs to identify gaps in quality and development in the implementation of a change of long-standing opioid culture and practice, which include customizing analgesics for the patient.18 Various states have implemented policies or guidelines setting limits on the supply of opioids that can be prescribed for acute pain.19 As of December 2021, 38 states have such policies.19 Two of these states have no set limit for opioid prescriptions but require doctors to prescribe the lowest effective dose19; such policies can create a gray area. What is the lowest effective dose? Should the lowest effective dose be procedure based, patient based, set in stone, or some combination?
In 2018, Overton et al16 emphasized a procedure-specific approach for opioid prescribing. Specifically, they used a 3-step modified Delphi method involving a multidisciplinary expert panel of 6 relevant stakeholder groups to create acceptable opioid ranges for common procedures in opioid-naive patients16; of note, Overton et al16 set the opioid recommendation range for open reduction internal fixation for an ankle fracture at 0 to 20 “pills.” Although a procedure-specific or procedure-first approach may indeed help misguided clinicians, particularly overprescribers, the ranges fail to take into consideration parameters beyond patients’ opioid history.16 Furthermore, Overton et al16 concede that any approach should be patient centered.
In 2021, Bleicher et al17 (n = 596) noted that opioid prescribing was rarely patient centered, with little correlation between patients’ inpatient opioid use and discharge after abdominal surgery at a single institution; the study suggests that many folks use a one-size-fits-all strategy regardless of the patient’s actual pain on discharge. Furthermore, the lack of patient-centered prescribing led not only to overprescribing for most patients but also to underprescribing.17 An example of overprescribing was discharging patients with opioids who had no opioid use 24 hours before their discharge.17 To our knowledge, the study by Bleicher et al is one of the first to examine patient-centric opioid prescribing. Building off the work of Overton et al16 and Bleicher et al,17 we propose a modified approach, the patient-centric and procedure-focused approach.
The patient-centric and procedure-focused approach is best suited to help combat both overprescribing and underprescribing of opioids while defending the physician-patient relationship.20 Opioid-prescribing approaches should be tailored to the patient’s unique pain tolerance and opioid history among other parameters.21,22 Prescribers should access a patient’s social determinants of health and baseline quality of life to gain additional insight23,24; for example, single patients who live alone will not have a spouse or partner to help them,25 which may result in an increased risk of weightbearing against medical advice and/or bumping the foot after surgery. In general, opioid prescribing should also be procedure focused. A digital amputation should not require as many opioids as a total ankle replacement, especially in a neuropathic patient. Furthermore, soft-tissue procedures of the foot and ankle tend to require fewer opioids than osseous procedures.21,26 There is an art to opioid prescribing, which is complicated and cannot be fully accounted for by any single approach because it enters into the realm of the physician-patient relationship.27 The physician-patient relationship is built on trust, knowledge, regard, and loyalty.27 Patient-dependent factors, system-dependent factors, provider-dependent factors, and patient-provider mismatch can impact the physician-patient relationship.27 The patient-centric and procedure-focused approach defends this sacred relationship.
There are a few limitations of the presented study. First, the low response rate limits generalization of the findings to all of the podiatrists practicing in the United States. Furthermore, nonresponse bias was not assessed; the sample may be inherently different than the overall population. Second, there may be a discrepancy between what respondents reported that they would do and what they actually do. Third, although we attempted to capture the represented population via the APMA, its membership may not accurately serve as a proxy for the entire podiatric physician population in the United States. Finally, despite several inherent limitations, the presented study was the first attempt to investigate podiatric physicians’ opioid-prescribing approaches; a lack of previous literature on the subject may have led to additional bias or errors.
Conclusions
Podiatric physicians who used a one-size-fits-all opioid-prescribing approach reported prescribing more postoperative opioids compared with those who used a patient-centric and procedure-focused approach. Given that the patient population that requires foot surgery is diverse and may have multiple comorbidities, the management of postoperative pain, likewise, should be diverse and nuanced. The patient-centric and procedure-focused approach is best suited to limit excess prescribing while defending the physician-patient relationship. Further research into the postoperative opioid-prescribing habits of podiatric physicians and other surgeons is warranted.
Acknowledgment: 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.
Dual Publication: This abstract won first place in the large study category at the annual scientific meeting of the American Podiatric Medical Association (“The National”) in Nashville, TN, in July of 2023.
Note: The first author was inspired to investigate this topic after reading about by the life of Saint Boniface; consequently, he prefers to call this customized approach to managing pain the “Saint Boniface Approach.”
References
- 1↑
Dyer O: A record 100 000 people in the US died from overdoses in 12 months of the pandemic, says CDC. BMJ 375: n2865, 2021.
- 2↑
Brown G, Susskind D: International cooperation during the COVID-19 pandemic. Oxf Rev Econ Policy 36: S64, 2020.
- 3
Larach DB, Waljee JF, Hu HM, et al.: Patterns of initial opioid prescribing to opioid-naive patients. Ann Surg 271: 290, 2020.
- 4
Weiner SG, Price CN, Atalay AJ, et al.: A health system–wide initiative to decrease opioid-related morbidity and mortality. Jt Comm J Qual Patient Saf 45: 3, 2019.
- 5
Brooks BM, Shih CD, Bratches RWR, et al.: Cognitive bias in postoperative opioid-prescribing practice. JAPMA 113: 1, 2023; doi: https://doi.org/10.7547/21-215.
- 6
Schieber LZ, Guy GP Jr, Seth P, et al.: Trends and patterns of geographic variation in opioid prescribing practices by state, United States, 2006-2017. JAMA Netw Open 2: e190665, 2019.
- 7
Bicket MC, Long JJ, Pronovost PJ, et al.: Prescription opioid analgesics commonly unused after surgery: a systematic review. JAMA Surg 152: 1066, 2017.
- 8
Lipari RN, Park-Lee E: Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. SAMHSA. 2020. Available at: https://www.samhsa.gov/data/. Accessed February 17, 2021.
- 9
Brooks BM, Shih CD, Brooks BM, et al.: The diabetic foot-pain-depression cycle. JAPMA 113: 1, 2023; doi: https://doi.org/10.7547/22-126.
- 10↑
Zhang H, Tallavajhala S, Kapadia SN, et al.: State opioid limits and volume of opioid prescriptions received by Medicaid patients. Med Care 58: 1111, 2020.
- 11↑
Davis CS, Piper BJ, Gertner AK, et al.: Opioid prescribing laws are not associated with short-term declines in prescription opioid distribution. Pain Med 21: 532, 2020.
- 12
APMA 2020 Poster Abstracts Competition. APMA.org. 2020. Available at: http://www.apma.org/files/FileDownloads/SummerSeriesPosterAbstracts.pdf. Accessed November 20, 2021.
- 13↑
Brooks BM, Brooks BM, Brooks BM, et al.: Postoperative opioid prescribing practice in foot and ankle surgery. JAPMA [March 3, 2021; doi: https://doi.org/10.7547/20-223].
- 14
Brooks BM, Li Q, Fleischer AE, et al.: Postprocedural opioid-prescribing practice in nail surgery. JAPMA 113: 1, 2023; doi: https://doi.org/10.7547/21-139.
- 15↑
Lipari RN, Williams M, van Horn SL: Why do adults misuse prescription drugs? In: The CBHSQ Report. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2013–2017. Available at: http://www.pubmed.ncbi.nlm.nih.gov/28968046/. Accessed October 9, 2021.
- 16↑
Overton HN, Hanna MN, Bruhn WE, et al.: Opioid-prescribing guidelines for common surgical procedures: an expert panel consensus. J Am Coll Surg 227: 411, 2018.
- 17↑
Bleicher J, Stokes SM, Brooke BS, et al.: Patient-centered opioid prescribing: breaking away from one-size-fits-all prescribing guidelines. J Surg Res 264: 1, 2021.
- 18↑
Smith RG: Mitigating the opioid crisis for the lower extremity provider opioid stewardship programs. Foot (Edinb) 45: 101708, 2020.
- 19↑
Opioid prescription limits and policies by state. Ballotpedia. 2021. Available at: https://ballotpedia.org/Opioid_prescription_limits_and_policies_by_state. Accessed March 8, 2022.
- 21↑
Bowlby MA, Crawford ME: Opioid crisis and acute pain management after foot and ankle surgery. Clin Podiatr Med Surg 36: 695, 2019.
- 22↑
Smith RG: Mitigating the shadow of the worldwide opioid crisis: a review for the foot and ankle specialist. Foot Ankle Spec 13: 242, 2020.
- 24↑
Christensen J, Ipsen T, Doherty P, et al.: Physical and social factors determining quality of life for veterans with lower-limb amputation(s): a systematic review. Disabil Rehabil 38: 2345, 2016.
- 25↑
Koren C: Together and apart: a typology of re-partnering in old age. Int Psychogeriatr 26: 1327, 2014.
- 26↑
Kvarda P, Hagemeijer NC, Waryasz G, et al.: Opioid consumption rate following foot and ankle surgery. Foot Ankle Int 40: 905, 2019.
- 27↑
Chipidza FE, Wallwork RS, Stern TA: Impact of the doctor-patient relationship. Prim Care Companion CNS Disord 17: 10.4088/PCC.15f01840, 2015.
Appendix
Checklist for Reporting Results of Internet E-Surveys (CHERRIES)
Appendix 2. Patient Scenarios
Patient 1.
A 56-year-old woman with a history of poorly controlled type 2 diabetes mellitus (hemoglobin A1c [HbA1c] level, 10.5%), hypertension, and a BMI of 35 presents for a neuropathic ulceration of the left second toe due to clawing of digit. The patient is unsure of when it began but noticed stains on her carpet when she went barefoot. The left second digit is rigidly contracted. The ulceration is purulent and probes deep to bone. Radiographic findings are consistent with osteomyelitis. The patient denies pain and use of opioids.
Operation: Left second partial toe amputation.
Patient 2.
A 67-year-old man with a history of poorly controlled type 2 diabetes mellitus (HbA1c level, 9.5%), hypertension, hyperlipidemia, and stage 2 chronic kidney disease presents for chronic sub–fifth metatarsophalangeal joint plantar neuropathic ulceration. The ulceration began almost 1 year ago and has been worsening the past few weeks. Previously, the patient had been following up at a wound care center for serial debridement but stopped going because his ulceration never hurt him. He now reports 2 of 10 pain. You note fluctuance on examination, and plain film radiographs are concerning for soft-tissue emphysema and osteomyelitis of the fifth metatarsal head as well as the base of the fifth proximal phalanx. His 1-month-old noninvasive vascular studies were normal. Patient has palpable dorsalis pedis/posterior tibial pedal pulses. He denies previous opioid use and has been taking over-the-counter ibuprofen for pain.
Operation: Right lateral forefoot incision and drainage with a partial fifth-ray amputation
Patient 3.
A 57-year-old man with a history of poorly controlled type 2 diabetes mellitus (HbA1c level, 12.7%), stage 1 chronic kidney disease, and a previous left partial first-ray amputation presents with a chronic left second sub–metatarsophalangeal joint wound that probes to bone. The ulceration is red, hot, swollen, and warm with purulence. The patient reports no pain. Protective sensation is absent plantarly and diminished elsewhere to the level of the ankle joint. Radiographs reveal underlying osteomyelitis of the second metatarsal head and proximal shaft. Palpable dorsalis pedis/posterior tibial pulses bilaterally. Vascular laboratory studies suggest good healing potential. The patient reports never taking opioids.
Operation: Left transmetatarsal amputation with a percutaneous tendon Achilles lengthening
Patient 4.
A 55-year-old nondiabetic man with a history of cauda equina complicated by paraplegia presents with a chronic right heel pressure ulcer that probes to bone. The ulceration began more than a year ago. There is radiographic evidence of osteomyelitis of the right calcaneus on radiographs and magnetic resonance images. Patient had previously undergone 6 weeks of intravenous antibiotics. The wound has continued to worsen despite multiple attempts at off-loading. Palpable pedal pulses bilaterally. The patient has chronic pain due to his spinal cord injury and regularly takes hydrocodone 10 mg.
Operation: Right partial calcanectomy
Patient 5.
A 62-year-old man with a history of poorly controlled type 2 diabetes mellitus (HbA1c level, 9.5%), lower back pain, hypertension, hyperlipidemia, peripheral artery disease, and Charcot’s neuroarthropathy is referred to you for foot pain. Patient has bounding pedal pulses and reports 4 of 10 pain. His magnetic resonance images reveal a deep abscess secondary to his Charcot’s neuroarthropathy. You perform an incision and drainage of the deep abscess, after which the resulting wound is too large for primary closure; even after the use of negative pressure wound vacuum-assisted closure therapy, which improved the wound depth, the wound remains open. The patient reports daily use of hydrocodone 5 mg for his low back pain.
Operation: Debridement and application of a split-thickness skin graft to the right plantar midfoot
Appendix 3. Consent Statement
Postoperative Narcotic-Prescribing Practices in Podiatric Limb Salvage Surgery.
Hello! We are interested in understanding the postoperative prescribing practices of podiatric physicians following limb salvage surgeries. We are inviting you to participate in this questionnaire-based research study because of your expertise and experience as a podiatric physician practicing in the United States. This questionnaire contains five hypothetical patient scenarios based on an aggregate of patients seen by podiatric physicians. Participation is voluntary, and we appreciate your input. Please review the entire form before agreeing to participate if you choose to do so.
This study is being conducted by:
Brandon Brooks, DPM; Co-Primary Investigator, Dartmouth College, Geisel School of Medicine.
Kristina Wolff, PHD MPH; Co-Primary Investigator, Dartmouth College, Geisel School of Medicine
Please ask any questions you have now. If you have questions later, you may contact Brandon Brooks, DPM, at brandon.m.brooks.gr@dartmouth.edu or Kristina Wolff, PhD, at Kristina.b.wolff@dartmouth.edu
Procedures:
If you agree to be in this study, please answer questions to the best of your ability. If a question is not completely applicable to you, you may either skip the question or answer “what you would have done” in that situation. Please only take the survey once. This questionnaire should take approximately 10 to 15 minutes of your time.
Confidentiality and Anonymity:
Your responses and information collected via the questionnaire will be maintained confidentially. The results of this study will be kept private and only reported in aggregate. Identifying information will not be used in any presentation or paper written about this project. Research records will be stored securely, and only the co-primary investigators will have access to the raw data.
Voluntary Nature of the Study:
Participation in this study is voluntary. If you decide to participate, you are free to not answer any question or to withdraw at any time. If you decide not to participate, we appreciate your time and consideration.
Statement of Consent:
I have read the above information and agree to take part in the study.
Yes
No
