SLR - November 2021 - Sarah A. Gostich

New Persistent Opioid Use After Orthopaedic Foot and Ankle Surgery

Reference: Emily E. Hejna, MPH; Nasima Mehraban, MD; George B. Holmes, Jr, MD; Johnny L. Lin, MD; Simon Lee, MD; Kamran S. Hamid, MD, MPH; Daniel D. Bohl, MD, MPH. New Persistent Opioid Use After Orthopaedic Foot and Ankle Surgery. J Am Acad Orthop Surg. 2021;29(16):e820-e825.

Level of Evidence: III

Scientific Literature Review

Reviewed By: Sarah A. Gostich, DPM
Residency Program: Bethesda Hospital – Baptist Health - South Florida

Podiatric Relevance: The opioid epidemic is a devastating public health issue to which orthopedic surgery is inextricably linked. Pain management is an important consideration when treating our patients undergoing orthopedic foot and ankle surgery. We need to weigh the benefits and consequences very carefully when we are managing peri-operative pain and we need to understand the long-term risk for our patient population.  

Methods: Patients undergoing orthopedic foot or ankle surgery at a single institution were identified. The state's prescription monitoring program was used to track opioid prescriptions filled in the preoperative (six months to 30 days before surgery), perioperative (30 days before to 14 days after), and postoperative (two to six months after) periods. Patients filling a prescription during the preoperative period were excluded. Baseline characteristics, surgical characteristics, and perioperative morphine milligram equivalents were tested for association with new persistent use during the postoperative period.

Results: A total of 348 opioid-naive patients met the inclusion criteria. Overall, the rate of new persistent postoperative opioid use was 8.9 percent. Patients reporting recreational drug use had the highest risk, at 26.7 percent (relative risk [RR] = 3.3, 95 percent confidence interval, 1.3 to 8.2, P = 0.0141). In addition, patients who had perioperative opioid prescription >160 morphine milligram equivalents were at increased risk (RR = 2.2, 95 percent confidence interval, 1.1 to 4.5, P = 0.021). Other risk factors included age ≥40 years (RR = 2.2, P = 0.049) and consumption of ≥ 6 alcoholic beverages per week (RR = 2.1, P = 0.040). New persistent use was not associated with ankle/hindfoot surgery (versus midfoot/forefoot), bone surgery (versus soft-tissue), or chronic condition (versus acute; P > 0.05).

Conclusions: The findings of the present study suggest that new persistent opioid use is a prevalent complication among opioid-naive orthopedic foot and ankle patients undergoing surgery, with about one in 11 such patients developing new persistent use during the postoperative period. This is alarmingly high and as foot and ankle surgeons we should take pause. Greater perioperative opioid prescription is a risk factor for new persistent use and is modifiable. Other risk factors include recreational drug use, greater alcohol use, and greater age.

I believe there is much more to examine than just our peri-operative opioid prescription protocols. Are we contributing to the ever-growing chronic pain population? We need to individualize our risk vs reward analysis when discussing surgical vs conservative treatment for patients. Additionally, surgical approach should be evaluated thoughtfully (minimally invasive/mini-open/open). We can also minimize risk for our surgical patients by implementing narcotic alternatives. We can lean on our anesthesia colleagues to advise us on better peri-operative pain management tactics, including long-acting local anesthesia and regional blocks. Our responsibility and due diligence extends far beyond the operating room and we owe it to our patients to improve. 

Educational Opportunities