March 2019

A REVIEW FOR LOWER-EXTREMITY SPECIALISTS: Mitigating the Opioid Crisis with Pain Management Regimens in a Multimodal Approach #900309188

For help limiting the number of opioid tablets you prescribe—and to still treat postop pain successfully—turn to practice guidelines, evidence from the literature about local and regional anesthesia techniques, and constraints of the law.

By Robert G. Smith, DPM, MSc, RPh, CPed, CPRS

Opioid abuse is among the most consequential and preventable public health threats in the United States1; many of these analgesic medications are associated with a high likelihood of physical dependence and a relatively high risk of addiction. This is a critical problem that needs to be addressed by all health-care professions.

To manage patients’ pain after invasive procedures, all practicing clinicians prescribe medication on occasion; the central theme of this article is responsible opioid pain management by lower-extremity specialists. I’ll describe prescription opioid strategies for use in alleviating lower-extremity pain, as well as how modern clinical-based evidence has led to ethical prescribing standards and legal regulations aimed at alleviating the widespread crisis we face. My goals? To have lower-extremity practices establish 1) procedures to better control and limit opioid prescriptions and 2) opioid monitoring strategies to recognize and reduce the risk of aberrant opioid misuse and abuse,2 and develop analgesic regimens to treat pain.*

*See “For lower-extremity specialists: Key points in opioid analgesic prescribing,” page 29.2,3 Elsewhere,2, 4-7 the author has discussed [within the scope of lower-extremity pain management] the pharmacology, pharmacodynamics, and pharmacokinetics of opioid analgesics, as well as opioid drug–drug interactions and adverse effects.

Opioids or non-opioids? Or both?

Analgesic opioid therapy has been the cornerstone of pharmacotherapeutic management of acute and chronic pain. Ideally, opioid analgesics are prescribed by balancing beneficial and adverse effects. Although often overlooked as a source of opioid medications, podiatric and orthopedic surgical interventions are often painful postoperatively; therefore, these specialists are frequent opioid prescribers.5

No single opioid analgesic is perfect, and no single agent can treat all types of pain.5,8 The underlying rationale for combination analgesic strategies involves the availability of individual agents that induce analgesia through separate or overlapping mechanisms or that have separate adverse effect profiles. The basic goal of a combination strategy is to amplify desired effects while decreasing, or at least not equally increasing, the undesired effects of individual agents.5, 8

“Opioid abuse is among the most consequential and preventable public health threats in the United States”

Many treatments are available to manage pain. Some non-opioid therapies are likely to be as effective as, or more effective than, opioids, and, potentially, carry less risk when used appropriately. Any meaningful effort to improve pain management will require a basic culture shift in the nation’s approach to mandating pain-related education for all health-care professionals who provide care to people with pain.

Prescribing guidelines may be most effective when accompanied by education; therefore, an evidence-based national approach to pain education that addresses pharmacotherapeutic and nonpharmacotherapeutic treatments and includes materials on opioid prescribing, is needed.2,5,9,10 The appropriate combination of agents, including opioids and adjunctive medications, can be seen as rational pharmacotherapy, providing a stable therapeutic platform on which treatment changes can be based:

  • Reassessing the pain score and level of function, regularly reassessing the patient, and combining this effort with corroborative support from family and other knowledgeable third parties; doing so will help document the rationale for continuing or modifying the therapeutic trial.
  • Regularly assessing the “4 As” of pain medicine: routine assessment of Analgesia, Activity, Adverse effects, and Aberrant behavior.5,9,10
  • Periodically reviewing the pain diagnosis and comorbid conditions, including addictive disorders and any underlying illness. The findings of diagnostic tests change with time; in the pain and addiction continuum, it is not uncommon for a patient to move from a dominance of one disorder to another. As a result, the treatment focus might need to change over time.

From the literature: Strategies to reduce the need for opioids


Key Points in Opioid Analgesic Prescribing2,3

It is critical that lower-extremity specialists first, understand the underlying issues of opioid prescribing and, second, exercise sound clinical judgment in identifying patients who might have, or develop, physical or psychological dependence on these drugs. Such understanding includes:

  • knowing that opioid analgesics should be prescribed by balancing their beneficial and adverse effects2
  • managing pain while minimizing abuse potential through careful procedural techniques and use of alternative therapies, by limiting prescriptions to appropriate quantities when opioids are deemed necessary, and by altering the attitudes of patients and physicians2
  • providing pain management responsibly in an error-free environment, adhering to state and federal regulations (such as Centers for Disease Control and Prevention guidelines that help providers manage pain effectively amid the opioid crisis)3
  • awareness that providers are not insulated from medical errors, medication misfortune, or ethical and legal responsibilities when prescribing opioid medication.

Published clinical-based evidence has described the effects of employing local anesthetic products to reduce postoperative pain and reduce the need for opioid analgesics:

Osteotomy. Kim et al. investigated 30 consecutive patients who underwent bilateral proximal osteotomy for correction of a hallux valgus deformity.11 Each patient acted as his (her) own control: 1 foot received local infiltration of a test solution made with ropivacaine, morphine, ketorolac, and epinephrine; the other foot received the same amount of normal saline. A visual pain analogue scale was used to assess pain intensity 4 hours after surgical intervention and throughout the night of the first postoperative day.

Finding: The difference in visual analogue scale values between left and right sides was most notable 8 hours after the operation, then gradually decreased through the first and second postoperative days. The investigators concluded that the local multidrug cocktail was easy to perform, safe, and effective in reducing pain and enhancing patient satisfaction after hallux valgus surgery.

Talar and calcaneal fracture repair. Luiten et al.12 investigated their hypothesis that a continuous peripheral-nerve block would reduce the pain score more effectively than systemic analgesics, improve recovery, and reduce length of stay. They retrospectively analyzed 3 years of data from patients who underwent open reduction and internal fixation of talar or calcaneal fracture and received 1) intravenous opioid, patient-controlled analgesia or 2) continuous peripheral-nerve block.

Finding: On the first postoperative day, the patient-controlled analgesia group (which had unrestricted access to opioids) required approximately 30-fold more opioids than the continuous peripheral-nerve block group (which had to request additional opioids).

Mitchell-Kramer osteotomy. Gadek and Liszka13 evaluated the influence of local anesthetic infiltration before hallux valgus surgery on postoperative pain and the need for analgesics. Their study group comprised 134 patients who underwent chevron or mini-invasive Mitchell-Kramer osteotomy of the first distal metatarsal. Each patient was randomized to receive 7 mL of local anesthetic (4 mL of bupivacaine, 0.25%, and 3 mL of lidocaine, 2%) or normal saline 15 minutes prior to skin incision. Each patient’s level of pain was assessed by the visual analogue scale at Hours 2, 4, 8, 12, 16, and 24, and again 72 hours after release of the tourniquet.

Finding: The authors concluded that preemptive local anesthetic infiltration significantly decreased pain during the first 24 hours after hallux valgus surgery. #155132832

Foot and ankle surgery. Gupta et al14 investigated the number of narcotic tablets taken by opioid-naïve patients undergoing outpatient foot and ankle surgery with regional anesthesia. Their patient population was 84 patients who underwent outpatient surgery using spinal blockade and a long-acting popliteal anesthetic block.

Patients were given 40 or 60 narcotic tablets, a 3-day supply of ibuprofen, deep-vein thrombosis prophylaxis, and an antiemetic. A survey completed at postop Days 3, 7, 14, and 56 documented whether they were still taking narcotics, how many pills they consumed, whether refills were obtained, pain level, and their reason for stopping opioids, if that was what they had done.

Finding: Patients consumed a mean of 22.5 tablets (95% confidence interval, 18-27 tablets). Those  who received regional anesthesia reported a progressively lower pain score with low narcotic use, for as long as 56 days postoperatively.

Foot and ankle surgery. Saini et al15 conducted a prospective investigation to evaluate utilization patterns and prescribing guidelines for opioid consumption after foot and ankle surgery. Their study population included patients undergoing outpatient orthopedic foot and ankle procedures who met inclusion criteria. The following prospective information was collected: patient demographics, preoperative health history, patient-reported outcomes, anesthesia type, procedure type, and opioid prescription and consumption details. The morphine milligram equivalent dosage was calculated for each prescription, then converted to the equivalent of a 5-mg oxycodone “pill.”

Univariate analyses were performed to identify variables with a statistically robust association with opioid consumption, for inclusion in a multivariable linear regression model. A stepwise backward regression was then performed to identify independent predictors of opioid consumption. Postoperative opioid utilization was reported for 988 patients (mean age, 49 years).

Finding: Overall, patients consumed a median of 20 pills; the median number prescribed was 40. The study revealed that these patients were overprescribed narcotic medication in an amount nearly twice what they consumed.

Postop analgesia protocol. Boffeli and Gorman16 recently described creation of a postoperative pain protocol using a multimodal approach that involves various medications used in the preoperative setting to tackle difficult lower-extremity pain pathways.

Finding: One year after adopting the pain protocol, the authors had reduced the amount of opioids prescribed postoperatively by 30% by adding non-steroidal anti-inflammatory agents to the protocol—without an incident of delayed union or nonunion.

Rescue therapy. Suzuki and Birnbaum17 asserted that opioid medication may have a role as rescue medications, but only as a last resort for neuropathic pain.

Reducing opioid use: Challenging, but doable

Multimodal analgesia for lower-extremity surgery is widely practiced as a means of reducing the use of opioids and opioid-related adverse effects. A multimodal approach is likely to produce analgesia superior to an opioid-based approach because multimodal analgesic agents target a variety of pain pathways. Furthermore, many non-opioid multimodal agents are inexpensive and offer benefit by reducing consumption, and, therefore, adverse effects of opioids.

Lower-extremity providers face the challenging task of setting appropriate protocols when balancing pain relief and regulatory guidelines. A clinical evidence base has revealed that the use of regional local anesthesia techniques during lower-extremity procedures has decreased consumption of opioids. Using a combination of the clinical evidence base that I’ve reviewed here, clinical practice guidelines (see “Suggested reading on pain management using opioids,” page 33), and state- and federally-legislated opioid limitations, the lower-extremity clinician can begin to reduce the number of opioid tablets prescribed to treat acute, chronic, and postsurgical pain.

Robert G. Smith is in private podiatry practice at Shoe String Podiatry in Ormond Beach, Florida. He has been an advisor to the US Food and Drug Administration and the US Drug Enforcement Administration regarding the rescheduling of hydrocodone combinations. He has delivered presentations on the appropriate prescribing of opioids to avoid drug–drug interactions, adverse effects of opioids, and avoidance of opioid abuse disorder at meetings of state, national, and international professional organizations in 2017 and 2018.

Suggested Reading on Pain Management Using Opioids

This listing of guidelines for using opioids to manage acute and chronic pain, developed by professional organizations and government agencies, is certainly not exhaustive and does not necessarily represent the views of the author or Lower Extremity Review.

Guideline for Prescribing Opioids for Chronic Pain – United States 2016

Centers for Disease Control and Prevention

Opioid Prescribing: Acute and Postoperative Pain Management

American Association of Oral and Maxillofacial Surgeons

Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus

Opioids after Surgery Workgroup of the American College of Surgeons

Oregon Acute Opioid Prescribing Guidelines

Public Health Division, Oregon Health Authority

Postoperative Opioid Prescribing Guidelines: Background for Surgeons

City of Philadelphia Department of Public Health

  1. Manchikanti L, Sanapati J, Benyamin RM, et al. Reframing the prevention strategies of the opioid crisis: focusing on prescription opioids, fentanyl, and heroin epidemic. Pain Physician. 2018;21(4):309-326.
  2. Smith RG. Opioid prescribing: podiatric implications. Podiatry Management. 2018;37(5):161-169. Accessed January 20, 2019.
  3. Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. .
  4. Smith RG. A review of opioid analgesics frequently prescribed by podiatric physicians. J Am Podiatr Med Assoc. 2006;96(4):367-373.
  5. Smith RG. Using clinical-based evidence as the sextant to prescribe and navigate through the opioid crisis. Foot and Ankle Quarterly. 2018;29(3):143-157.
  6. Smith RG. Drug interactions and opioids: what you should know. Podiatry Today. 2018:31(4). Accessed January 20, 2019.
  7. Smith RG. Opioid prescribing and the opioid crisis in the lower extremity. Advance Research on the Foot and Ankle: ARFA-106. 2018;2018(1):1-7.
  8. Raffa RB, Clark-Vetri R, Tallarida RJ, et al. Combination strategies for pain management. Expert Opin Pharmacother. 2003;4(10):1697-1708.
  9. Bonnie RJ, Ford MA, Phillips JK, editors; National Academies of Sciences, Engineering, and Medicine. Consensus Study Report: Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: The National Academies Press; July 12, 2017. Accessed January 20, 2019.
  10. Passik SD, Weinreb HJ. Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Adv Ther. 2000;17(2):70-83.
  11. Kim BS, Shim DS, Lee JW, et al. Comparison of multi-drug injection versus placebo after hallux valgus surgery. Foot Ankle Int. 2011;32(9):856-860.
  12. Luiten WE, Schepers T, Luitse JS, et al. Comparison of continuous nerve block versus patient-controlled analgesia for postoperative pain and outcome after talar and calcaneal fractures. Foot Ankle Int. 2014;35(11):1116-1121.
  13. Gdek A, Liszka H. Preemptive local anesthetic infiltration in hallux valgus one-day surgery. Przegl Lek 2015;72(1):16-19.
  14. Gupta A, Kumar K, Roberts MM, et al. Pain management after outpatient foot and ankle surgery. Foot Ankle Int. 2018;39(2):149-154.
  15. Saini S, McDonald EL, Shakked R, et al. Prospective evaluation of utilization patterns and prescribing guidelines of opioid consumption following orthopedic foot and ankle surgery. Foot Ankle Int. 2018;39(11):1257-1265.
  16. Boffeli T, Gorman C. A guide to postoperative pain management. Podiatry Today. 2018;31(9):48-54.
  17. Suzuki K, Birnbaum Z. Pain management and wound care patients: key principles. Podiatry Today. 2018;31(12):36-41.

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