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Opioid Prescribing and Consumption Trends in Foot & Ankle Surgery

HEE W. KIM, BS



SUMMARY POINTS

  • An average of 34 opioid pills are prescribed to patients following foot & ankle surgeries, with approximately half going used.

  • Patients who underwent forefoot surgeries exhibited less opioid consumption than those with hindfoot/ankle surgeries.

  • Excess over-prescribing of opioids after foot & ankle surgeries can result in opioid abuse and diversion.

ANALYSIS


Background


From supporting the full body weight to enabling exercise and ambulating for daily activities, the feet and ankles are crucial to the quality of the human experience. With nearly 1 in 5 people experiencing foot and ankle pain at any moment, it is imperative to understand the implications of opioids in podiatric pain management (1).

Opioid prescriptions are traditionally provided in conjunction with other adjunct therapies after foot & ankle procedures. However, the surge in opioid addiction and overdose-related deaths poses difficulty in balancing the opioid crisis with proper postoperative care. As surgical volume increases each year, the risk of opioid dissemination also increases, only contributing to the opioid epidemic (2). Therefore, understanding the opioid prescription and consumption trends of varying foot & ankle surgeries can help limit over-prescribing and opioid diversion.

Findings


Between 2005 and 2014, about 285,162 foot & ankle surgeries were performed by orthopedic and podiatric surgeons (2). Of those procedures, 154,835 were performed by podiatric surgeons (54%) and 130,327 by orthopedic surgeons (46%). Procedure types varied between the two professions: orthopedists specialized more in hindfoot/ankle and Achilles tendon repairs, while podiatrists focused more on the forefoot and midfoot procedures (Figure 1).



Figure 1. Common Foot & Ankle Problems Treated by Physicians. Reprinted from: Thomson Reuters Market Scan survey data for 2010 commercial health insurance claims (https://www.apma.org/Advocacy/content.cfm?ItemNumber=28605)

Saini et al. suggested that the anatomical location of the procedure within the foot (forefoot, midfoot, hindfoot/ankle) can have different implications on opioid consumption (3). Research shows that individuals consumed fewer opioid pills after forefoot surgery than after hindfoot surgery. Interestingly, no significant difference in opioid consumption was seen with midfoot surgeries (4). While it is easily assumed that different levels of postoperative visual analog scale (VAS) pain scores may influence opioid consumption, studies have shown that there are no significant differences in postoperative pain scores between procedures on different anatomical locations of the foot (Figure 2) (4).


Figure 2. Forefoot/Midfoot vs Hindfoot Surgery VAS Scores. Reprinted from: Makvana S et al. Are Hindfoot Procedures More Painful than Forefoot Procedures? A Prospective Observational Study in Elective Foot and Ankle Surgery. J Foot Ankle Surg. 2022.

Considering the quantity of opioid pills prescribed, on average, 33.9 pills were prescribed after foot & ankle surgeries (n=244, Figure 3) (5). However, only 45.7% of the initially prescribed pills were consumed, resulting in 4,496.6 pills leftover for potential diversion. Similar findings were reported by Saini et al. where a median of 20 pills were consumed (a median of 40 pills initially prescribed) (3). Additionally, when looking at differences in opioid consumption between bony and soft tissue procedures of the foot, data suggests that individuals who underwent bony procedures consumed more pills than individuals with soft tissue procedures (Figure 4) (5). Likewise, patients consumed fewer pills after elective surgeries than after trauma-related surgeries.





Figure 3. Overall Prescription and Consumption Details. Reprinted from: Kvarda P et al. Opioid Consumption Rate Following Foot and Ankle Surgery. Foot Ankle Int. 2019.


Figure 4. Operative Group-Specific Prescription and Consumption. Reprinted from: Kvarda P et al. Opioid Consumption Rate Following Foot and Ankle Surgery. Foot Ankle Int. 2019.

Other studies have raised concerns over opioid prescribing for minor ankle injuries across the U.S, despite a lack of conclusive studies and evidence-based findings (6). In general, opioid prescribing for ankle sprains is common but variable. However, the consensus is that opioids should be avoided as first-line pain management treatment (7).

Discussion

The studies above clearly delineate the current issue of opioid over-prescribing rates in foot & ankle surgeries: a vast number of opioids is prescribed despite the low average patient consumption rate. Furthermore, opioid prescribing rates and guidelines seem to differ amongst different institutions and states of the U.S., suggesting a need for a clear, uniform approach to combat the opioid crisis (8).

Data also depicted the varying opioid consumption trend amongst different foot & ankle surgeries. However, very little is known about the true cause and effect of issues, such as why patients consume more opioids than elective surgery patients and why opioid consumption differs between hindfoot/ankle and forefoot surgeries. Future studies should consider the influences of different foot & ankle surgical techniques, patient recovery expectations, and patient education on postoperative opioid consumption. Limitations to these studies may include a lack of control for body weight or BMI, which have known positive correlations with increased opioid prescription and consumption (9). Prescribers should consider these factors and current research findings to mitigate opioid over-prescribing.

Additionally, a press release by the American Medical Association in 2021 showed a discrepancy between opioid prescribing and overdose rates. According to the report, opioid overdose rates continue to increase while prescription rates have decreased by 44% (2011-2020) (10). These trends suggest other factors beyond opioid prescriptions contributing to the opioid crisis. Further research is needed to evaluate the extent that opioid prescribing plays in the changing landscape of the opioid crisis. REFERENCES

  1. Hill, CL, Gill, TK, Menz, HB, Taylor, AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide Health Study. J Foot Ankle

Res. 2008;1:2.

  1. Burton A, Aynardi MC, Aydogan U. Demographic Distribution of Foot and Ankle Surgeries Among Orthopaedic Surgeons and Podiatrists: A 10-Year Database Retrospective Study. Foot Ankle Spec. 2021 Jun;14(3):206-212. doi: 10.1177/1938640020910951. Epub 2020 Mar 13. PMID: 32167386.

  1. Saini S, McDonald EL, Shakked R, Nicholson K, Rogero R, Chapter M, Winters BS, Pedowitz DI, Raikin SM, Daniel JN. Prospective Evaluation of Utilization Patterns and Prescribing Guidelines of Opioid Consumption Following Orthopedic Foot and Ankle Surgery. Foot Ankle Int. 2018 Nov;39(11):1257-1265. doi: 10.1177/1071100718790243. Epub 2018 Aug 19. PMID: 30124084.

  1. Makvana S, Faroug R, Venturini S, Alcorn E, Gulati A, Gaur A, Mangwani J. Are Hindfoot Procedures More Painful than Forefoot Procedures? A Prospective Observational Study in Elective Foot and Ankle Surgery. J Foot Ankle Surg. 2022 Jan- Feb;61(1):23-26. doi: 10.1053/j.jfas.2021.04.024. Epub 2021 Jun 11. PMID: 34325971.

  1. Kvarda P, Hagemeijer NC, Waryasz G, Guss D, DiGiovanni CW, Johnson AH. Opioid Consumption Rate Following Foot and Ankle Surgery. Foot Ankle Int. 2019 Aug;40(8):905-913. doi: 10.1177/1071100719848354. Epub 2019 May 21. PMID: 31113306.

  1. Finney FT, Gossett TD, Hu HM, Waljee JF, Brummett CM, Walton DM, Talusan PG, Holmes JR. Rate of Opioid Prescriptions for Patients With Acute Ankle Sprain. Ann Intern Med. 2019 Sep 17;171(6):441-443. doi: 10.7326/M19-0679.

  1. Delgado MK, Huang Y, Meisel Z, Hennessy S, Yokell M, Polsky D, Perrone J. National Variation in Opioid Prescribing and Risk of Prolonged Use for Opioid-Naive Patients Treated in the Emergency Department for Ankle Sprains. Ann Emerg Med. 2018 Oct;72(4):389-400.e1. doi: 10.1016/j.annemergmed.2018.06.003. Epub 2018 Jul 24. PMID: 30054152; PMCID: PMC6319263.

  1. Sears JM, Fulton-Kehoe D, Schulman BA, Hogg-Johnson S, Franklin GM. Opioid Overdose Hospitalization Trajectories in States With and Without Opioid-Dosing Guidelines. Public Health Rep. 2019 Sep/Oct;134(5):567-576. doi: 10.1177/0033354919864362. Epub 2019 Jul 31. PMID: 31365317; PMCID: PMC6852059.

  1. Stokes A, Lundberg DJ, Sheridan B, et al. Association of Obesity With Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US. JAMA Netw Open. 2020;3(4):e202012. doi:10.1001/jamanetworkopen.2020.2012

  1. American Medical Association. Report shows decreases in opioid prescribing, increase in overdoses. 2021.https://www.ama-assn.org/press-center/press-releases/report-shows- decreases-opioid-prescribing-increase-overdoses

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