Prescribing Fewer Opioid Pills to Patients Undergoing Foot and Ankle Surgery: A Prospective Comparative Study

CATEGORY: Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Sports; Trauma; Other INTRODUCTION/PURPOSE: This study aims to compare a novel opioid prescribing protocol aimed at reducing the number of opioid pills prescribed and consumed with an established, previously published protocol for foot and ankle surgery. We hypothesized that patients in the novel group would consume fewer opioids and report similar satisfaction with pain management compared with the established group. METHODS: This study is a single center prospective study of 59 patients undergoing foot and ankle surgery who received a novel opioid prescribing protocol used by the senior author. Preoperatively, patients were counseled on the expectations of pain after surgery, received a take home pamphlet, and were prescribed opioids based on a sliding scale of procedures designated as minor (0-5 pills), moderate (5-10 pills) or major (15-20 pills). These patients were then compared to 84 patients from a previous prospective study from the same institution who received an opioid prescribing protocol with a maximum of 40-60 opioid pills. Patients were excluded if they used opioids or muscle relaxants preoperatively or had a known history of a substance use disorder. Patients completed surveys postoperatively for eight weeks reporting pain level, number of opioid pills consumed, refill requests, and satisfaction with their pain management plan. RESULTS: There was a significant difference (p< 0.001) in mean pills consumed between the novel and established prescribing protocols at all time points (Table 1). During the entire postoperative period patients in the novel group had taken 21% of their prescribed pills compared to 40% in the established group (p=0.03). Patients had comparable levels of pain throughout the study (p>0.05 at POD 3, POD 7 and POD 14) and only differed significantly at POD 56 (p=0.005). Patients in the novel group did not request any refills, whereas patients in the established group requested a total of 9 refills over the course of the study. CONCLUSION: Patients receiving fewer opioid medications, along with preoperative coaching and take home materials, achieved equivalent analgesic effect when compared to patients receiving approximately double the amount of opioids. This study demonstrates that a sliding scale protocol with a maximum prescription of 20 opioid pills provides appropriate pain relief for most patients. This study confirms that patients on average take far fewer opioid pills than prescribed, and likely an even more limited prescribing protocol would be adequate for the majority of patients. This novel prescribing protocol ensures less opioids are both consumed and leftover for potential diversion in the community.