SLR - March 2015 - Kathie J. Whitt

The Effect of Preoperative Counseling on Duration of Postoperative Opiate Use in Orthopaedic Trauma Surgery: A Surgeon-Based Comparative Cohort Study

Reference: Holman JE, Stoddard GJ, Horwitz DS, Higgins TF. The Effect of Preoperative Counseling on Duration of Postoperative Opiate Use in Orthopaedic Trauma Surgery: A Surgeon-Based Comparative Cohort Study.  J Orthop Trauma. 2014 Trauma. 2014 Sep; 28(9): 502-6.

Scientific Literature Review

Reviewed By:
Kathie J. Whitt, DPM
Residency Program: Grant Medical Center

Podiatric Relevance: As foot and ankle surgeons we routinely address acute and perioperative pain with the use of opiate pain medication. With the contemporary increase seen in US prescriptions, there has also been a notable increase in deaths related to opiate overdose. In fact, the US currently reports greater than 12,000 deaths per year secondary to prescription drug overdose. This being said, there continues to be no specific guideline on the appropriate duration of postoperative opiate treatment. There is also no established data on the effect of physician counseling on the duration of opiate use pos-toperatively and the role we as surgeons have in establishing these patient expectations. As surgeons, it is important we address opiate use appropriately and are able to treat acute surgical pain without sending patients down a path of self-destruction.

Methods: This retrospective review included Utah residents with an isolated, operative musculoskeletal injury, admitted to a single orthopedic trauma service over the course of 24 months. The patients were divided into two separate groups with two separate trauma surgeons. Prior to their initial procedure, group one was instructed that they would receive opiate pain medication for a maximum of six weeks. The second group was not counseled on the duration of opiate use. The study evaluated the presence and frequency of opiate use before injury, cessation by six weeks, cessation by 12 weeks and continuation of opiates greater than 12 weeks post-operatively.    

Results: Six hundred thirteen patients met inclusion criteria as described above. In comparing the two groups, the study found that patients who were informed at the time of surgery that they would only receive a max of six weeks of opiates were more likely to stop use by six weeks compared to those that were not counselled, 73 percent vs 64 percent respectively. By 12 weeks no statistical difference was seen and after 12 weeks approximately 20 percent of patients continued to take opiates regardless of preoperative counseling.  The authors therefore concluded that patients receiving preoperative counseling had a 26 percent decreased risk of continuing opiate use beyond 6 weeks.

Conclusions: There are many overlapping factors related to patient demographics when comparing musculoskeletal trauma with those at risk for substance abuse and addiction including socioeconomic status, level of education, and personality types. It is therefore essential that we find a balance in treating postoperative pain and exposing patients to the risk of addiction and death. This article found that a brief, preoperative conversation with patients providing them with an appropriate timeline to cessation will decrease their risk 26 percent. This is clinically significant and ultimately should be consider for all perioperative planning. 

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