SLR - June 2019 - Natalie Alexandra Coriaty
New Persistent Opioid Use Following Common Forefoot Procedures for the Treatment of Hallux Valgus
Reference: Finney F, Gossett T, Hu H, Waljee J, Brummett C, Talusan P, Holmes J. New Persistent Opioid Use Following Common Forefoot Procedures for the Treatment of Hallux Valgus. J Bone Joint Surg Am. 2019 Apr 17;101(8):722–729.
Scientific Literature Review
Reviewed By: Natalie Alexandra Coriaty, DPM
Residency Program: Kaiser Permanente Vallejo, North Bay Consortium, Vallejo, CA
Podiatric Relevance: Bunionectomies are one of the most commonly performed podiatric surgeries and are traditionally coupled with postoperative opioid prescriptions. As the opioid epidemic escalates to new heights, it is important to reassess how and when we prescribe these medications. Opioid prescribing guidelines for surgeons are still poorly delineated, which likely contributes to overprescribing. The authors assess the rate of persistent opioid use in opioid-naïve patients after a procedure that is ubiquitous in foot and ankle surgical practices.
Methods: Using insurance claims, the orthopaedic group compares opioid-naive patients who underwent a bunionectomy who had and had not filled perioperative (one month prior to two weeks after surgery) opioid prescriptions. The three types of bunionectomies included are the distal metatarsal osteotomy (DMO), metatarsal cuneiform (MC) fusion and a first metatarsal double osteotomy. The study defines persistent opioid prescriptions as those filled between 91 and 180 days, considering the first 90 days as normal acute postsurgical healing. Variables assessed included type of surgery, amount of opioids prescribed initially (in terms of oral morphine equivalents, OMEs), timing of the prescription relative to the procedure and patient demographics/comorbidities. Perioperative opioid dosing was compared using the 75 percent percentile of OME. A logistic regression model was used to investigate opioid use between surgical techniques while controlling for variable patient factors.
Results: Of the 41,687 patients included in the study, only 5,125 had not filled an opioid prescription perioperatively. Of the patients who had perioperative opioid prescriptions, those who had MC fusion had significantly higher rates of persistent opioid use (8.9 percent) than either the DMO or double osteotomy groups (7.6 percent and 7.2 percent, respectively). It also showed that on average, the MC fusion group had higher OMEs prescribed initially. The link between OMEs initially prescribed and occurrence of persistent opioid use was the most consequential and modifiable finding of the study. This was also reflected in the comparison of patients who had and had not filled perioperative opioid prescriptions (2.3 percent vs. 6.2 percent, respectively with persistent prescriptions). Finally, it was shown that patients with comorbidities and mental health disabilities had a higher instance of persistent opioid use.
Conclusion: Although the bunionectomy is a pervasive and relatively minor pedal surgery, postoperative pain management should not be taken lightly. The present study reveals the high rates of persistent opioid use after bunion surgery. The study also reflected briefly on the importance of patient counseling, particularly in high-risk patients. Creating realistic postoperative pain expectations for patients likely plays an important role in the number of opioid pills prescribed. While it provided reason to reduce initial opioid prescribing, it failed to reflect specific OME levels necessary for pain management. Future research must build on the present study to evidence the average minimum OME needed to address postoperative pain after bunion procedures for specific guidelines. In the future, it may be wise to consider starting with smaller opioid prescriptions and adding more as needed rather than starting with a large dose.