Perioperative Pain Control in Upper Extremity Surgery: Prescribing Patterns, Recent Developments, and Opioid-Sparing Treatment Strategies

Labrum, Joseph T.; Ilyas, Asif M.

doi:10.1177/1558944718787262

Cited by 19 publications

(22 citation statements)

References 21 publications

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“…This study also highlights the tendency for surgeons to overprescribe opioids following upper extremity surgeries, 16-22 as half of our patients did not consume any opioids. Patients consumed a mean of 5 tablets over the first 7 postoperative days, yet each patient received a prescription for 20 tablets.…”

Section: Discussionsupporting

confidence: 53%

“…These numbers are consistent with other studies in the literature, with mean postoperative opioid consumption numbers cited as 3.0 to 4.3 pills after carpal tunnel release. 18 Gauger et al 19 recently analyzed several articles on opioid use after upper extremity surgeries and found that surgeons tend to prescribe 2 to 5 times more opioids than patients actually consume. In a prospective evaluation of opioid consumption patterns, Kim et al 20 identified specific prescribing guidelines after they determined surgeons prescribed approximately 3 times the number of opioid pills consumed by their patients.…”

Section: Discussionmentioning

confidence: 99%

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Prospective, Double-blind Evaluation of Perioperative Intravenous Acetaminophen and Ketorolac for Postoperative Pain and Opioid Consumption After Endoscopic Carpal Tunnel Release

Truelove

Urréchaga

Fernandez³

et al. 2020

Hand (New York, N,Y.)

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Background: The current opioid epidemic highlights the need for pain management strategies to decrease or eliminate postoperative use of opioid medications. The purpose of this study was to determine if perioperative administration of intravenous (IV) acetaminophen and/or IV ketorolac decreases postoperative pain and opioid consumption after endoscopic carpal tunnel release. Methods: In all, 44 subjects were enrolled in this randomized, double-blind, placebo-controlled study from October 2015 to April 2017 and divided into 4 treatment arms: placebo, IV acetaminophen, IV ketorolac, or both IV acetaminophen and IV ketorolac. Patients recorded pain at 8-hour intervals on an 11-point scale and daily opioid use for 7 days after surgery. Analysis of variance and Kruskal-Wallis tests were used to compare mean pain scores and opioid consumption. Results: Mean pain scores over the 7-day study period were lower in the placebo and IV acetaminophen groups. Patients in the placebo and acetaminophen groups reported less pain than those in the ketorolac and combination groups on postoperative days 6 and 7. Patients administered IV acetaminophen had lower daily mean opioid usage. In all, 50% of the patients did not take any opioids after surgery. Conclusions: There are small, statistically significant differences in postoperative pain and opioid consumption supporting the use of IV acetaminophen for pain control after endoscopic carpal tunnel release, though these results are likely not clinically relevant. We recommend continued investigation into multimodal pain management in upper extremity surgery as well as limiting the number and quantity of opioid prescriptions provided to patients postoperatively.

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Section: Discussionsupporting

confidence: 53%

Section: Discussionmentioning

confidence: 99%

Prospective, Double-blind Evaluation of Perioperative Intravenous Acetaminophen and Ketorolac for Postoperative Pain and Opioid Consumption After Endoscopic Carpal Tunnel Release

Truelove

Urréchaga

Fernandez³

et al. 2020

Hand (New York, N,Y.)

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“…A perioperative multimodal analgesic regimen is recommended. 17 The authors prefer to position the patient in lateral decubitus with an arm post or in the supine position with a sterile padded Mayo stand. The bed is rotated 90° to facilitate intraoperative fluoroscopy and operating room setup.…”

Section: Surgical Technique: Im Screw Tbw Of Olecranon Fracturesmentioning

confidence: 99%

Augmented intramedullary screw tension band construct for olecranon fracture reduction and fixation: a review of literature and surgical technique

Labrum¹,

Foster²,

Weikert³

2020

JSES International

Self Cite

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Olecranon fractures, which make up 10% of upper extremity fractures in adults, often require anatomic reduction and stable internal fixation. Successful olecranon fracture osteosynthesis has classically been achieved via tension band wiring or plate fixation. This article reviews the indications, outcomes, and a surgical technique as an alternative construct for tension band wiring of olecranon fractures. The technique involves placement of an ulnar intramedullary partially threaded screw that is used as a proximal point of attachment for tension band wiring of the olecranon. Although infrequently used by orthopedic surgeons, this construct has been shown to be biomechanically and clinically superior to classic Kirschner wire tension banding techniques. This review is intended to familiarize surgeons with a surgical technique that can be applied to a variety of proximal ulna fractures.

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“… 29 Over the first decade of the 21st century, the opioid sales increased by 400%. 16 More recently, there has been a near 3-fold increase in the number of people with an opioid use disorder, 23 , 26 with the United States (US) making up 80% of the global opioid supply despite only representing 5% of the world’s population. 16 Most people’s first exposure to opioids is via prescription medication, 32 with many patients receiving prescriptions with the number of opioids well in excess of the number they will ultimately need to take for adequate pain control.…”

mentioning

confidence: 99%

“… 16 More recently, there has been a near 3-fold increase in the number of people with an opioid use disorder, 23 , 26 with the United States (US) making up 80% of the global opioid supply despite only representing 5% of the world’s population. 16 Most people’s first exposure to opioids is via prescription medication, 32 with many patients receiving prescriptions with the number of opioids well in excess of the number they will ultimately need to take for adequate pain control. 25 Orthopedic surgeons are among the leading prescribers of opiate medications, 23 and therefore, orthopedists have a substantial opportunity for improved opioid stewardship.…”

mentioning

confidence: 99%

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

et al. 2021

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Introduction Pain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery. Methods The Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months. Results Of the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group ( P < .001). On multivariate analysis, younger age, female gender, and tobacco use, along with the comorbidities of coronary artery disease, clinical depression, diabetes, and rheumatic disease were all found to be predictive factors of prolonged opioid use. Discussion The dose-dependent relationship observed between original opioid prescription data and number of additional refills needed, suggests that initially overprescribing opioids may lead to prolonged dependency. This study also identified several independent risk factors for prolonged opioid use, including younger age, depression, and tobacco use. This study will hopefully help recognize high-risk patient populations and serve as the foundation for future studies into opioid prescription standardization and preoperative opioid education.

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Perioperative Pain Control in Upper Extremity Surgery: Prescribing Patterns, Recent Developments, and Opioid-Sparing Treatment Strategies

Abstract: The authors advise hand surgeons to utilize the strategies discussed in this review to assist in forming a unique, patient-specific postoperative analgesic regimen.

Cited by 19 publications

References 21 publications

Prospective, Double-blind Evaluation of Perioperative Intravenous Acetaminophen and Ketorolac for Postoperative Pain and Opioid Consumption After Endoscopic Carpal Tunnel Release

Prospective, Double-blind Evaluation of Perioperative Intravenous Acetaminophen and Ketorolac for Postoperative Pain and Opioid Consumption After Endoscopic Carpal Tunnel Release

Augmented intramedullary screw tension band construct for olecranon fracture reduction and fixation: a review of literature and surgical technique

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

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