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Study Looks At Risk Factors For Post-Op Opioid Use

A poster abstract presented at the American College of Foot and Ankle Surgeons (ACFAS) Scientific Conference identifies risk factors for patients using opioids for four weeks after lower extremity surgery.

The authors reviewed the electronic medical records of 581 patients who had foot and ankle surgery, and found that 31 percent used opioids at four weeks post-op. The authors noted risk factors for patients using opioids a month after surgery included preoperative opioid use, surgery that targets both soft tissue and bone, tourniquet use for more than two hours, smoking and diabetes.

Given that 31 states now have limits for first-time opioid prescriptions and the tracking of opioid prescriptions with prescription drug monitoring programs is now required in all 50 states, Robert Smith, DPM, MSc, RPh, CPed, CPRS, believes a post-surgical intervention opioid prescription for four weeks would be considerably rare. For example, he says Florida state law mandates if patients need more than seven days of prescription opioids post-op, they should get a referral to a pain management specialist.

As Kieran Mahan, DPM, MS, FACFAS, notes, many insurance companies already limit the quantity and time period for the dispensing of narcotics after surgery. He adds that some insurers require narcotic contracts in order to pre-authorize the dispensing of narcotics postoperatively.

Preoperatively, Dr. Mahan, a Professor in the Department of Podiatric Surgery at the Temple University School of Podiatric Medicine, advises thoroughly discussing pain management with patients so doctor and patient expectations are the same. He will let patients know he does not expect them to need narcotic agents for more than two weeks. Dr. Mahan explains the risks of long-term opioid use and discusses the disposal of excess medication so nobody else in the family can misuse the opioids, which he calls “a major source of teen initiation into narcotics.”

Dr. Smith, who is in private practice in Ormond Beach, Fla., says the success of acute opioid pain therapy depends on proper candidate selection, assessment before administering opioid therapy and close monitoring throughout the course of treatment.

Ideally, Dr. Smith says one would screen for opioid risk factors for misuse and abuse on the patient’s first visit or before prescribing opioids. He adds that even patients who have been taking opioids for long periods of time should have routine screenings. He suggests using an Opioid Risk Tool, a patient self-reporting screening tool, which would enable clinicians to screen for risk factors for misuse and/or abuse based on the patient’s responses. Drs. Smith and Mahan say the essential items in a generic opioid risk tool are family history of substance abuse and a personal history of substance abuse. Dr. Smith adds that based on clinical experience and the literature, patients ages 16 to 45 have a higher incidence of opioid abuse as do those with a history of preadolescent sexual abuse or psychological disease.

Dr. Mahan notes the coexisting use of anti-anxiety agents “is a major red flag,” while a history of sexual abuse is another risk factor. Dr. Mahan also advises giving special consideration to aging patients who may be on several medications that together can increase the risk of falls, given a more limited ability to metabolize these agents.

“Many patients are now much more aware of the dangers of opioids and are, in general, more concerned about using them,” says Dr. Mahan.

Do Patients With Diabetes Have More Complications Following TAR?

By Brian McCurdy, Managing Editor

Complication rates following total ankle replacement (TAR) are not significantly higher in patients with diabetes, according to a poster abstract presented at the ACFAS Scientific Conference.

The authors focused on 28 patients who had total ankle replacements, 13 of whom had diabetes. The average follow-up was 34 months for those with diabetes and 32 months for those without the disease. The researchers note a total complication rate of 15.4 percent for patients with diabetes in comparison to 13.3 percent in those without diabetes. Complications in those with diabetes consisted of wound dehiscence.

Abstract lead author James Cottom, DPM, notes patient selection for implant arthroplasty is a specific subset within the general population. He and his colleagues select patients for TAR based on an in-depth vascular evaluation as well as an in-office neurologic evaluation. Basic labs, including A1c, complete blood cell count (CBC) and bone morphogenetic protein (BMP), will also help determine who is a good TAR candidate, according to Dr. Cottom, the Fellowship Director of the Florida Orthopedic Foot and Ankle Center in Sarasota, Fla.

For patients with diabetes who receive a total ankle replacement, Christopher Hyer, DPM, FACFAS, cites concerns of possible delayed incision healing, wound dehiscence and infection. As TAR is an elective procedure, he says surgeons can take the time to optimize glycemic control, get a vascular workup when necessary and counsel the patient on the importance of stable HbA1C control.

Surgeons should carefully screen out patients with poorly controlled or uncontrolled diabetes from elective surgery when possible, notes Dr. Hyer, the Co-Director of the Orthopedic Foot and Ankle Center Fellowship at the Orthopedic Foot and Ankle Center in Westerville, Ohio. In his opinion, diabetic neuropathy is a contraindication for TAR.

“A patient having diabetes is not an automatic exclusion criterion,” for total ankle replacement, says Dr. Cottom. “You need to dive deeper into the extent of the diabetes, the multi-organ effect of the disease and patient history.”

As Dr. Cottom explains, poorly controlled sugars may indicate one is not treating the most adherent patient with diabetes. He calls this a glimpse into the patient’s likely postoperative adherence, which he says can become very important if a complication develops.

Dr. Cottom says further research should consist of a retrospective analysis of patients who have had successful uneventful TAR outcomes in comparison to patients who had complications. He says an analysis of variance (ANOVA) test looking into common variables with complications would benefit practitioners. Dr. Hyer suggests a future prospective controlled study would further improve surgeon understanding of any increased risk posed by diabetes in TAR.

Study Suggests New Hepatic Wound Matrix May Help Heal DFUs

By Brian McCurdy, Managing Editor

A novel hepatic-derived wound matrix can effectively close hard-to-heal diabetic foot ulcers, according to an abstract to be presented at the Symposium on Advanced Wound Care Spring/Wound Healing Society meeting (SAWC Spring/WHS) next month.

The abstract focused on 38 patients with diabetic foot ulcers between 1 and 12 cm2 who received a decellularized, hepatic-derived wound matrix called Miroderm (Miromatrix Medical) in addition to standard wound care and sharp debridement. At an average follow-up of 12 weeks, 22 patients had healed with a mean time to wound closure of 8.1 weeks. The authors noted the 16 non-healed wounds had reduced in size by a mean of 63 percent.

As abstract lead author Robert Fridman, DPM, FACFAS, CWSP, notes, Miroderm is the only hepatic-derived matrix available in the wound care market. He says the matrix’s ability to close DFUs that are hard to heal is an advantage in his practice given the needs, long-term cost and overall quality of life for his patients. The matrix can stay in the wound bed for a few weeks during care and even when the product has been resorbed or integrated, there is a carryover effect until the next matrix application, according to Dr. Fridman, the President of the American College of Foot and Ankle Surgeons Northeast Region and a partner at Foot Associates of New York.  

Dr. Fridman notes that in the abstract and another study on the new matrix, researchers targeted DFUs of more than 90 days’ duration that had been unsuccessfully treated with other advanced biologics. Given the results in the studies for patients with hard-to-heal DFUs, he thinks the Miroderm wound matrix would have “even greater promise” in wounds at their first presentation for care.

“We need to continue to look at products that can help our patients close (wounds),” says Dr. Fridman. “The recent correlations between amputation and mortality are high and as a profession, we need to explore meaningful ways to avoid amputation if possible.”

SAWC Spring/WHS will be held from May 7-11 in San Antonio, Texas. For more info about SAWC Spring/WHS, visit www.sawcspring.com.

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By Brian McCurdy, Managing Editor
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