Are Foot And Ankle Surgeons Prescribing Too Many Opioids?

Foot and ankle surgeons prescribe post-op opioids at a rate twice as high as patients consume them, according to a recent study.

The study, published in Foot and Ankle International, reviewed the opioid usage by 988 patients who had outpatient orthopedic foot and ankle surgeries. The researchers note patients took a median of 20 opioid pills when the median number of prescribed pills was 40. The study identified four independent factors associated with the consumption of opioids: anesthesia type, age below 60 years, preoperative Visual Analog Scale (VAS) pain report of more than 6 and bony procedures. However, the authors add that there is a “substantial degree of unexplained variance” in prescription opioid use.

Troy Boffeli, DPM, historically has prescribed 40 tablets of opioid medication postoperatively but found patients only took about half this amount. He notes this led to a new protocol about one year ago in which he and his colleagues began prescribing 20 tablets.

“There was concern that this change would result in more phone calls and refills, but that was not our experience,” says Dr. Boffeli, who is in private practice at HealthPartners Specialty Center in St. Paul, MN. “Part of the protocol was to educate patients about what to do with leftover pills so that they do not become misused.”

Noting that he is not a surgeon, Robert Smith, DPM, MSc, RPh, CPed, CPRS, has rarely prescribed opioids and always limits the amount to a maximum or three days only. He will refer patients to chronic pain management if his treatment selection and medical pharmaceutical intervention did not meet the patient’s expectation. On those few occasions patients do take opioids, he refers patients to a pharmacy with a locked metal box for controlled substances or provides information centered on drug take-back programs that allow people with unused medications to bring them in for proper disposal.

Podiatric physicians are not overprescribing opioids, asserts Dr. Smith, who is in private practice at Shoe String Podiatry in Ormond Beach, FL. He cites a recent Podiatry Management survey of 1,039 podiatrists, who noted prescribing opioids at an equal to lower rate in comparison to their overall weekly prescriptions.

Dr. Smith believes both federal and state opioid prescribing regulations greatly impact how specialty physicians prescribe opioids. He cites the use of an national evidence-based approach to pain education, including pharmacologic and nonpharmacologic treatments, and materials on opioid prescribing as well as prescription drug monitoring programs to help address the opioid epidemic by allowing prescribers and other stakeholders to track prescribing and dispensing information.  

To prescribe opioids more effectively, Dr. Smith advises assessing the potential risks of opioids before prescribing, using treatment agreements with patients and using urine toxicology screens.

To control pain without overprescribing narcotics, Dr. Boffeli advises screening for high-risk patients (checking for past narcotic use or abuse, anxiety, addiction), educating patients about what to expect, and explaining why it is not a good idea to be on narcotics for weeks. He also advises developing a multimodal pain management regimen including scheduled acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) for primary pain control with reserved use of narcotic medications for breakthrough pain.

Can A New Porcine Liver Matrix Help Treat Chronic Wounds?

By Brian McCurdy, Managing Editor

An abstract to be presented next month at the Symposium on Advanced Wound Care (SAWC) Fall investigates the use of a new decellularized porcine liver wound matrix to treat diabetic foot ulcers (DFUs).

Researchers studied 24 patients with DFUs with a mean wound area of 3.4 cm² that had been present for 90 days or more, and who had received at least two treatments with advanced biologics. After receiving the decellularized porcine liver wound matrix (Miroderm, Miromatrix Medical), 11 patients healed within a mean 7.2 weeks, nine did not heal and four discontinued use of the matrix, according to the study abstract. Furthermore, four of the nine patients who were not healed in 12 weeks had closed by 80 percent or more and were trending toward 100 percent closed.

Lead study author Robert Fridman, DPM, FACFAS, CWSP, says when wounds stall, he usually employs an advanced biologic to help enhance the wound healing environment. He cites several advantages of the porcine liver wound matrix. Dr. Fridman says the hepatic-derived graft is a highly vascularized, collagen matrix unlike grafts derived from dermis, bladder or other tissues. This likely allows for enhanced revascularization and remodeling of wounds, notes Dr. Fridman, who is in private practice at Foot Associates of New York and an attending in the Department of Orthopaedic Surgery at Columbia University Medical Center. Dr. Fridman adds that the matrix’s perfusion decellularization process is gentler than the much harsher immersion decellularization of other acellular matrices, ensuring that Miroderm contains a full mix of beneficial proteins, cytokines and growth factors.

Dr. Fridman has used the matrix to treat DFUs, particularly those that are hard to heal, and had successful results. He suggests the matrix may have potential for surgical and trauma wounds, pyoderma and necrotizing fasciitis.

The SAWC Fall will be held Nov. 2–4 in Las Vegas. For more info, go to www.sawc.net/fall/ .

Randomized Study Says dHACM Is Effective For DFUs

By Brian McCurdy, Managing Editor

The results of a new randomized controlled trial, presented in the International Wound Journal, note that dehydrated human amnion/chorion matrix (dHACM) can effectively treat diabetic foot ulcers.

The study, conducted at 14 wound care centers, involved 98 patients with 47 receiving dHACM (EpiFix, MiMedx) and 51 who did not have dHACM. Researchers note that at a 16-week follow-up, 95 percent of 38 dHACM-healed ulcers remained closed in comparison with 86 percent of 28 healed ulcers that did not receive dHACM.

Lee C. Rogers, DPM, cites several advantages of EpiFix. He says the product’s growth factors can accelerate wound healing and the allograft is non-immunogenic. The allograft is also available in many sizes so physicians can choose a size-appropriate graft to reduce waste and limit costs, notes Dr. Rogers, the Medical Director of the Amputation Prevention Centers of America. However, he notes that as with all cellular and tissue-based products, multiple applications can become costly.

As EpiFix is minimally manipulated human tissue, Dr. Rogers says it falls under the Food and Drug Administration’s 361 HCT/P guidelines, meaning physicians can use it for acute or chronic wounds of any depth and any etiology.

In the future, Dr. Rogers notes covering bone and tendon with EpiFix will become more prominent “as this is a growing problem in the diabetic foot.” He adds that the micronized, injectable form of EpiFix is showing promise in applications other than wounds like plantar fasciitis, tendonitis and arthritis.