Opioid prescribing practices prior to elective foot and ankle surgery: a population-based evaluation using health administrative data from a tertiary hospital in Canada

Abstract

Background Complex elective foot and ankle surgery is known to be painful so most patients are prescribed opioids at the time of surgery; however, the number of patients prescribed opioids while waiting for surgery in Canada is unknown. Our primary objective was to describe the pre and postoperative prescribing practices for patients in Alberta, Canada undergoing complex elective foot and ankle surgery. Secondarily, we evaluated postoperative opioid usage and hospital outcomes. Methods In this population-based retrospective analysis, we identified all adult patients who underwent unilateral elective orthopedic foot and ankle surgery at a single tertiary hospital between May 1, 2015 and May 31, 2017. Patient and surgical data were extracted from a retrospective chart review and merged with prospectively collected, individual level drug dispensing administrative data to analyze opioid dispensing patterns, including dose, duration, and prescriber for six months before and after foot and ankle surgery. Results Of the 100 patients, 45 had at least one opioid prescription dispensed within six months before surgery, and of these, 19 were long-term opioid users (> 90 days of continuous use). Most opioid users obtained opioid prescriptions from family physicians both before (78%) and after (65%) surgery. No preoperative non-users transitioned to long-term opioid use postoperatively, but 68.4% of the preoperative long-term opioid users remained long-term opioid users postoperatively. During the index hospitalization, preoperative long-term opioid users consumed higher doses of opioids (99.7 ± 120.5 mg/day) compared to opioid naive patients (28.5 ± 36.1 mg/day) (p < 0.001). Long-term opioid users stayed one day longer in hospital than opioid-naive patients (3.9 ± 2.8 days vs 2.7 ± 1.1 days; p = 0.01). Conclusions A significant number of patients were dispensed opioids before and after foot and ankle surgery with the majority of prescriptions coming from primary care practitioners. Patients who were prescribed long-term opioids preoperatively were more likely to continue to use opioids at follow-up and required larger in-hospital opioid dosages and stayed longer in hospital. Further research and education for both patients and providers are needed to reduce the community-based prescribing of opioid medication pre-operatively and provide alternative pain management strategies prior to surgery to improve postoperative outcomes and reduce long-term postoperative opioid use.

Pain relief after major ankle and hindfoot surgery with repetitive peripheral nerve blocks: A feasibility study

“…Postoperative pain after major elective ankle and hindfoot surgery (ankle arthrodesis, subtalar arthrodesis, triple arthrodesis) is often severe for several days—especially the first two postoperative days 1,3,4,6. Daily mean in‐hospital opioid consumption has been reported at ranges of approximately 10–30 mg oral morphine‐equivalent doses15 (with much higher doses in intermittent or long‐term preoperative opioid users), despite multimodal analgesic regimes including single‐dose PNB or cPNB 6,9,16. Either single‐dose PNB or cPNB is conventionally recommended as a component of multimodal analgesia in order to alleviate postoperative pain after major ankle and hindfoot surgery 4.…”

“…[3][4][5] Opioids are a major component of conventional postsurgical multimodal strategies, which may have negative perioperative consequences due to the numerous adverse effects such as sedation, respiratory impairment, postoperative nausea and vomiting (PONV) and constipation. [4][5][6][7] This can impede early ambulation and prolong the length of stay. 5 In addition, opioids are relatively ineffective in alleviating postoperative pain compared to PNBs, especially during mobilisation.…”

“…Current modalities of postoperative analgesic treatment include peripheral nerve blocks (PNB)—either as single injection or continuous peripheral nerve blocks (cPNB) combined with paracetamol, NSAIDs and opioids 3–5 . Opioids are a major component of conventional postsurgical multimodal strategies, which may have negative perioperative consequences due to the numerous adverse effects such as sedation, respiratory impairment, postoperative nausea and vomiting (PONV) and constipation 4–7 . This can impede early ambulation and prolong the length of stay 5 .…”

Preoperative Opioid Use Predicts Poorer Outcomes of Total Ankle Arthroplasty and Hindfoot Fusions

“…8 -10 In addition to the finding correlating postoperative use to preoperative opioid use, there have also been studies indicating that increased dosage of postoperative opioid prescriptions can lead to greater opioid use following orthopaedic surgery. 11 -13 Furthermore, there is support of increased hospitalization duration associated with preoperative opioid use in numerous studies examining total joint arthroplasty, a factor providers should take into consideration when examining treatment options. 14 -16…”

“…[8][9][10] In addition to the finding correlating postoperative use to preoperative opioid use, there have also been studies indicating that increased dosage of postoperative opioid prescriptions can lead to greater opioid use following orthopaedic surgery. [11][12][13] Furthermore, there is support of increased hospitalization duration associated with preoperative opioid use in numerous studies examining total joint arthroplasty, a factor providers should take into consideration when examining treatment options. [14][15][16] Although there is little literature on the influence of preoperative narcotic use on ankle or hindfoot fusion, or TAA complication and reoperation rates, this effect has been thoroughly explored in other surgical subspecialties.…”