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How Effective Are Opioids At Relieving Chronic Pain?

Although opioids may help in treating chronic pain, a recent meta-analysis cautions that the pain relief effect is statistically significant but small.

The meta-analysis, published in the Journal of the American Medical Association, included 96 randomized clinical trials involving a total of 26,169 patients with chronic pain not due to cancer. The researchers noted the use of opioids was associated with significantly less pain (-0.69 cm less on the 10-point Visual Analogue Scale) and better physical functioning (2.04 on the Short Form 36) in comparison with placebo. However, the study authors warned the benefit of opioids was of a small magnitude and opioids caused an increased risk of vomiting.

Kristine Hoffman, DPM, FACFAS, uses the guideline of the Centers for Disease Control and Prevention (CDC) when assessing the benefits and harms of using opioids for pain. Using this guideline, Dr. Hoffman assesses patient pain and function and also takes into account the surgical procedure and anticipated opioid requirement to determine patients’ postoperative pain management.

To screen for risk, Dr. Hoffman evaluates multiple factors, such as patient or family history of substance abuse, anxiety or depression, age 65 or older, respiratory disease, renal disease and hepatic disease. She will also review the patient’s current medication list for current opioid or other medications that may cause respiratory depression, review labs for recent urine drug screening and check the Prescription Drug Monitoring Program for recent opioid prescriptions.

When it comes to treating chronic pain, Kazu Suzuki, DPM, CWS, relies on experience and trial and error. As he explains, every patient seems to have a choice of preferred pain meds, noting that one type works and another medication does not work. This applies to even something as simple as acetaminophen and to “heavy” drugs like oxycodone (OxyContin, Purdue Pharma), according to Dr. Suzuki, the Medical Director of the Tower Wound Care Centers at the Cedars-Sinai Medical Towers.

Dr. Suzuki prescribes opioids strictly for acute pain after surgical procedures, including wound debridement. Typically, Dr. Hoffman reserves opioids for postoperative use and significant traumatic injuries such as ankle and hindoot fractures. She finds that non-opioid modalities are best for managing pain from less severe injuries such as metatarsal fractures, tendon ruptures and lacerations.

“I do not prescribe opioids for chronic pain and feel this is best managed by a pain specialist or the patient’s primary care physician,” says Dr. Hoffman, the Medical Director of the Orthopedic Clinic and an Attending Physician in the Department of Orthopedics at Denver Health Medical Center.

In her experience, Dr. Hoffman has found multimodal analgesia to be “extremely beneficial” in managing chronic pain with greater pain relief and fewer side effects than opioids. She cites modalities including non-steroidal anti-inflammatory drugs (NSAIDs), topical local anesthetics, local anesthetic blocks, corticosteroid injections, neuropathic agents, topical capsaicin, transcutaneous electrical nerve stimulation (TENS) units, acupuncture and physical therapy.

For chronic pain, Dr. Suzuki cites the use of gabapentin (Neurontin, Pfizer) and the chemically similar and newer pregabalin (Lyrica, Pfizer), saying they work for many painful conditions and are prescribed widely as adjunctive pain medications, along with Tylenol and/or tramadol, a prescription schedule IV synthetic opioid. Dr. Suzuki notes many of his patients self-medicate with edible cannabidiol (CBD) oil, a medical marijuana compound with anti-inflammatory, sleep-inducing and pain relieving properties, which he may recommend to patients who have exhausted other pain control options for neuropathy or other chronic pain conditions. 

Study Compares Complication Rates For Inpatient And Outpatient Total Ankle Arthroplasty 

By Brian McCurdy, Managing Editor

Total ankle arthroplasty has similar complication rates whether patients have the procedure on an inpatient or outpatient basis, according to a recent study in the Journal of Foot and Ankle Surgery.

The study focused on 591 patients who had total ankle arthroplasty, 66 of whom were outpatients. The study notes those who had arthroplasty as an inpatient procedure had higher rates of superficial surgical site infections, deep surgical site infections, organ/space surgical site infections, pneumonia and return to the operating room although researchers say the differences were not significant. The authors note the study shows outpatient total ankle arthroplasty is “safe and may be a superior option for certain populations.”

Lawrence DiDomenico, DPM, FACFAS, has yet to perform an outpatient total ankle arthroplasty but his nearly 19 years of experience with total ankle arthroplasty have shown him that some of his procedures could have been done on an outpatient basis.

“Believe it or not, many times we did try to schedule some (it has to be the right patient) as an outpatient and Medicare would not approve (the procedure) to be done (on) an outpatient (basis),” notes Dr. DiDomenico, the Section Chief of the Department of Podiatry at St. Elizabeth Hospital in Youngstown, Ohio.  

Dr. DiDomenico says other foot and ankle surgeons are beginning to do total ankle replacement as an outpatient service, but he advises proper patient selection. He notes an outpatient must have pre-op physical therapy for non-weightbearing training and be medically stable. Following surgery, Dr. DiDomenico says one should monitor patients’ hemoglobin and hematocrit. He notes home health care should assist with post-op management, including helping with post-op drain management and with deep vein thrombosis (DVT) prophylaxis, which can include support hose, sequential compression pumps and anticoagulation therapy. Dr. DiDomenico adds that a popliteal block would assist with the initial pain.

As Dr. DiDomenico notes, malleolar fractures are the most common complication intraoperatively with total ankle arthroplasty. He says this is generally related to inexperience but can also occur with even an experienced surgeon based on the implant and approach one uses. The best way to reduce malleolar fractures, he notes, is to pre-pin the the malleolus with K-wires.

Wounds are another common complication and Dr. DiDomenico points out that since the foot and ankle have a very thin soft tissue envelope, any significant mismanagement of the soft tissues can be costly and cause a wound. He notes incision planning and tissue handling can prevent wound complications, and a lateral approach appears to be much less involved with wounds than an anterior approach.

Is PRP Better Than Platelet-Poor Plasma For Plantar Fasciitis?

By Brian McCurdy, Managing Editor

A recent study notes that while platelet-rich plasma (PRP) does improve pain and function for patients with chronic plantar fasciitis, its effects are not significantly better than platelet-poor plasma.

The double-blinded, randomized, prospective study, published in Foot, involved 36 patients with chronic plantar fasciitis. Eighteen patients had a single ultrasound-guided PRP injection and 18 patients had platelet-poor plasma injections with the same technique. At three- and six-month follow-ups, the researchers noted both groups experienced improved scores in pain, function and satisfaction, but there were no statistically significant differences between the two groups.

Lawrence Oloff, DPM, says PRP for plantar fasciitis “represents a viable treatment option for plantar fasciitis,” calling it superior to platelet-poor plasma. Before using PRP for heel pain, he cautions that physicians should first try traditional options such as orthotics, physical therapy, night splints, non-steroidal anti-inflammatory drugs and cortisone injections. If traditional treatments do not work, one might consider PRP or extracorporeal shockwave therapy before proceeding to surgery, says Dr. Oloff, the Podiatric Medicine and Surgery Residency Program Director at St. Mary’s Medical Center in San Francisco.

Bob Baravarian, DPM, FACFAS, notes that in PRP, the “magic” of the treatment is the buffy coat, the part of an anticoagulated blood sample containing most of the white blood cells and platelets following the density gradient centrifugation process.

Platelet-rich plasma is better when the physician wants an increased inflammatory response to a chronic injury that can start the body’s trigger for healing, says Dr. Baravarian, an Assistant Clinical Professor at the UCLA School of Medicine, and the Director and Fellowship Director at the University Foot and Ankle Institute in Los Angeles. He says platelet-poor plasma facilitates less inflammation and more healing cells.

Dr. Oloff cites advantages to PRP for plantar fasciitis, including the treatment’s relatively low risk in comparison to surgery. He notes the disadvantages of PRP include its expense, which is often not covered by insurance. Dr. Oloff says having ultrasound skills is preferable when administering PRP.

News and Trends
By Brian McCurdy, Managing Editor
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