Podiatric physicians and surgeons have been on the forefront of managing acute pain for decades.1–4 As the United States opioid epidemic has worsened, a variety of strategies have been used to mitigate the public health crisis.2,5–7 Many prescribers in the United States now utilize opioid use agreements for patients with chronic pain.8–10 These same opioid use agreements for chronic pain can be modified and used for outlining a course of action for managing acute pain.8–10
Proper documentation is the professional and legal responsibility of all providers. Foot and ankle surgery further necessitates pain management documentation due to a patient-centric and procedure-focused nature of the specialty. Firstly, many podiatric physicians and surgeons operate on patients with altered epicritic and protopathic sensation, such as those in the diabetic population.11–14 Brooks et al1 and Hearty et al15 demonstrated that postoperative pain management variation exists among American surgeons on the national level in this specific population for both opioids and non-narcotics. Secondarily, patients undergoing foot and/or ankle surgery for arthritis may have comorbidities that prevent them from using various non-opioid analgesics, such as acetaminophen with nonalcoholic fatty liver disease (NAFLD) and nonsteroidal anti-inflammatory drugs (NSAIDs) with chronic kidney disease (CKD). Like many chronic diseases, osteoarthritis, NAFLD, and CKD are associated with advanced age.16–18 Thirdly, the offloading required in many foot and ankle surgeries may result in compensatory pain elsewhere.19 Fourthly, amputations can result in the unique complication of phantom limb pain.20,21
While podiatric physician and surgeons are skilled at managing acute pain, no clinician—regardless of specialty—should hesitate to make an appropriate referral to pain management for chronic pain. Globally, pain management is increasingly recognized as a formal medical subspecialty worldwide given the complex interplay of medical, psychological, and social issues associated with pain.22 Prior to performing surgery, the podiatric physician and surgeon should have a conversation with their patient on the postoperative pain expectations. For example, opioids used by the patient for their postoperative pain should be expected to be short-term. Including an opioid use agreement for acute pain within the informed consent for surgery can help facilitate these important conversations, educate the patient on the addiction potential of opioids, and establish reasonable expectations with the patient.23,24
Utilizing opioid use agreements for acute pain is not without precedent.23 In 2022, Williams et al23 examined the impact of opioid consent for acute pain in orthopedic trauma surgery in the pediatric population and reported that the proportion of patients prescribed opioids (P = 0.0378) and the number of doses (P < 0.001) were lower in consented patients (n = 1,793). Further, in the adjusted analysis, preoperative opioid consent (P = 0.013) was associated with fewer prescribed opioid doses.23 In order to create an opioid use agreement for acute pain for podiatric physician and surgeons, we modified existing acute pain opioid agreements and applied existing literature to bolster it (Fig. 1).1,25–27
Opioid Use Agreement in Foot and Ankle Surgery.
Citation: Journal of the American Podiatric Medical Association 113, 4; 10.7547/23-045
Informed consents for anticipated long-term opioid therapy are commonplace. However, given that opioid addiction for many patients starts with management of acute pain, an informed consent establishes reasonable expectations and helps to protect both the provider and the patient when it is determined that acute pain has converted to chronic pain. Informed consent for opioid use ensures a safe, patient-centered care approach, managing acute pain for patient comfort and establishing a referral pathway for pain management when indicated.
Acknowledgment: The first author was inspired to promote the inclusion of a detailed opioid use agreement for acute pain after reading about the life of Saint Lidwina and subsequently prefers to refer to these opioid use agreements as “St. Lidwina Agreements.”
Financial Disclosure: None reported.
Conflict of Interest: None reported.
References
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