JOSEPH LABRUM, IV, MD
ASIF ILYAS, MD, MBA
Hand Surgery is a high volume surgical field with historically excessive prescribing of opioids.
Pre-operative opioid counseling results in decreased post-operative opioid consumption.
Peri-operatively, the use of NSAIDs, acetaminophen, and infiltration of the surgical site with local anesthetics decreases post-operative pain and opioid consumption.
Post-operative opioid prescription should be based on procedure type and location, with common soft tissue hand surgeries not routinely requiring opioids post-operatively.
Hand Surgery is a high volume surgical specialty performed by Orthopaedic Surgeons, Plastic Surgeons, and General Surgeons in the management of surgical problems of the hand, wrist, and arm. Pain management in hand surgery must balance patient satisfaction with goals of accelerating postoperative recovery, decreasing length of stay, and maximizing the number and complexity of surgical interventions provided in an ambulatory setting.1 This Research Brief will outline treatment strategies designed to maintain effective pain management in hand and upper extremity surgery while minimizing opioid delivery available for diversion, misuse, and abuse. Evidenced-based recommendations will be divided into pre-operative, peri-operative, and post-operative pain management strategies.
Pre-Operative Opioid Prescribing
A careful pre-operative history and clear communication of reasonable peri-operative expectations are important to successful post-operative recovery and opioid cessation. In addition to a traditional upper extremity examination, hand surgeons should also screen patients for a history of substance use and dependence, as well as risk factors that can predispose to opioid related morbidity or mortality. These risk factors include catastrophic thinking, personal or family history of substance abuse, depression or other psychiatric illness, current tobacco use, young age, joint or fracture surgery, prior surgical interventions of the upper arm, unemployment, workers’ compensation, and self-pay or Medicaid-insurance status.2,3 During pre-operative evaluations, patients should be informed of the inherent risks of opioid analgesics as well as the ultimate goal of rapid post-operative opioid cessation. Alter and Ilyas, who carried out a prospective, randomized study analyzing the effect of pre-operative opioid counseling on post-operative opioid consumption found that patients undergoing carpal tunnel release surgery randomized to receive preoperative opioid counseling consumed significantly fewer (two-thirds less) opioid pills in the acute postoperative period (POD 0-5), were more likely to utilize nonopioid analgesics, and experienced no significant difference in pain scores compared with patients who received no counseling.4 In addition, the standardized pre-operative counseling utilized in this study both educated patients on opioids and also provided 5 recommendations:
(1) Understand risk factors for opioid abuse and addiction pre-operatively.
(2) Encourage use of non-opioid analgesics, prior to utilizing prescription opioids post-operatively.
(3) Surgeon should clearly define the expected post-operative pain and length of opioid therapy.
(4) Surgeon should prescribe the lowest dose and shortest duration of therapy that is efficacious.
(5) Determine whether opioid analgesics are currently being prescribed by any other provider (primary care physicians, pain management specialist, etc.) and coordinate expectations, goals, and duration of opioid therapy anticipated.
Peri-Operative Opioid Prescribing
Hand surgeons have many intra-operative anesthetic and analgesic techniques available from which to choose, varying from wide-awake surgery with local anesthesia alone to general anesthesia. Common anesthetic techniques available in upper extremity surgery include wide-awake with only local anesthesia and no tourniquet technique, continuous peripheral nerve blocks, upper extremity regional blocks, and general anesthesia. The choice of these peri-operative anesthetic strategies can have a significant effect on postoperative pain experience and opioid consumption.
A simple and effective technique in minimizing post-operative pain is the infiltration of local anesthesia directly into the surgical site prior to incision placement intra-operatively. Labrum & Ilyas identified that the use of the infiltration of 0.5% of bupivacaine into the thumb basal joint arthroplasty surgical site resulted in decreased post-operative pain and opioid consumption compared to cases performed without local injection, with all cases otherwise being performed under just general anesthesia alone.5 Similarly, multi-modal pain management strategies have been employed in various surgical specialties with success. Non-steroidal anti-inflammatory drugs (NSAIDs) in particular have a long track record of success in the management of peri and postoperative pain.6 A randomized controlled study in Hand Surgery by Sai et al. analyzed the effects a brachial plexus block with or without preemptive analgesia observed that preoperative ampiroxicam resulted in significantly improved pain control and decreased opioid consumption following hand surgery.7 More recently, intravenous acetaminophen has become available. In a prospective randomized double-blinded trial examining intravenous acetaminophen versus ketorolac following endoscopic carpal tunnel release identified success with the use of intravenous acetaminophen in decreasing post-operative pain.8
Post-Operative Opioid Prescribing
Adequate pain control following hand surgery can be challenging. In addition, while excessive analgesia must be avoided, inadequate pain control can lead to insufficient rehabilitation, poor surgical outcome, increased morbidity, and decreased patient satisfaction.9 Despite the need for adequate post-operative pain management, recent research aimed at quantifying opioid prescribing indicates that hand surgeons are inadvertently dispensing excess opioids in the post-operative period than typically needed. Rogers et al. conducted a prospective evaluation of prescribing patterns following upper extremity surgery in 250 patients where patients were prescribed 30 opioid pills post-operatively, while typically only 10 opioid pills were consumed.10 Overall, the 250-patient cohort was in possession of 4639 unused opioid pills at the 2-week postoperative timepoint. Similarly, Kim et al carried out a prospective study on 1416 patients undergoing upper extremity surgery and also observed that approximately two-thirds of prescribed opioids went unused.11 Subsequently, a number of studies have been performed that have identified the typical opioid consumption by pill count for common hand and upper extremity surgeries. (Table 1)
Post-operative opioid utilization rates following common hand and upper extremity surgeries. (Adopted with permission from Labrum & Ilyas – HAND 2019).
Ideally, opioids should be prescribed based on typical consumption patterns rather than outlying patients. Based on studied consumption patterns, Kim et al utilized their opioid consumption data to create of a comprehensive set of intervention-specific opioid prescribing guidelines. (Table 2) Adalbert & Ilyas examined satisfaction with these prescribing guidelines confirming high satisfaction and low refill rates post-operatively.12
Recommended post-operative opioid prescribing guidelines
(Adopted with permission from Labrum & Ilyas – HAND 2019).
Moreover, in common soft tissue hand surgeries such as carpal tunnel release, trigger finger release, and mass excision surgeries; opioids may not even be necessary post-operatively. In a prospective cohort study examining post-operative pain management after carpal tunnel release surgery, Miller et al. identified that tramadol was as effective as oxycodone in managing post-operative pain management.13 Additionally, in a prospective randomized double-blinded trial by Ilyas et al. comparing acetaminophen, ibuprofen, and oxycodone after either carpal tunnel release or trigger finger release surgeries found no difference in post-operative pain, medication consumption, and satisfaction.14 The study findings support the use of non-opioids following common soft tissue hand surgeries.
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Adalbert JR, Ilyas AM. Implementing Prescribing Guidelines for Upper Extremity Orthopedic Procedures: A Prospective Analysis of Postoperative Opioid Consumption and Satisfaction. HAND (N Y). 2019 Aug 23;1558944719867122. (e-pub ahead of print).
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