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• W2904650830 abstract "The opioid epidemic is the subject of much debate and research within all medical fields. Notable work has been done in hand surgery. The purpose of this article is to review the recent literature as it pertains to opioid use in hand surgery. The scope of the current problem is identified and mitigating strategies are described. More studies are necessary to evaluate the efficacy of these strategies. The opioid epidemic is the subject of much debate and research within all medical fields. Notable work has been done in hand surgery. The purpose of this article is to review the recent literature as it pertains to opioid use in hand surgery. The scope of the current problem is identified and mitigating strategies are described. More studies are necessary to evaluate the efficacy of these strategies. The use of prescription opioids in the United States has been increasing steadily over the past several decades.1Kuehn B.M. Opioid prescriptions soar: increase in legitimate use as well as abuse.JAMA. 2007; 297: 249-251PubMed Google Scholar, 2Manchikanti L. Helm II, S. Fellows B. et al.Opioid epidemic in the United States.Pain Physician. 2012; 15: ES9-ES38Crossref PubMed Google Scholar Orthopedic surgeons prescribe more opioids than any other surgical field3Jiang X. Orton M. Feng R. et al.Chronic opioid usage in surgical patients in a large academic center.Ann Surg. 2017; 265: 722-727Crossref PubMed Scopus (146) Google Scholar, 4Volkow N.D. McLellan T.A. Cotto J.H. Karithanom M. Weiss S.R.B. Characteristics of opioid prescriptions in 2009.JAMA. 2011; 305: 1299-1301Crossref PubMed Scopus (617) Google Scholar and upper-extremity surgeons specifically tend to overprescribe opioids for postoperative analgesia. In many instances, surgeons overprescribe relative patients’ actually needs for pain management.5Rodgers J. Cunningham K. Fitzgerald K. Finnerty E. Opioid consumption following outpatient upper extremity surgery.J Hand Surg Am. 2012; 37: 645-650Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar The opioid epidemic has resulted in an increase in opioid-related deaths, which is currently at an all-time historic high, with a tremendous financial burden to society.2Manchikanti L. Helm II, S. Fellows B. et al.Opioid epidemic in the United States.Pain Physician. 2012; 15: ES9-ES38Crossref PubMed Google Scholar Several studies suggested that surgery is a risk factor for chronic opioid misuse, abuse, and dependence.6Alam A. Gomes T. Zheng H. Mamdani M.M. Juurlink D.N. Bell C.M. Long-term analgesic use after low-risk surgery: a retrospective cohort study.Arch Intern Med. 2012; 172: 425-430Crossref PubMed Scopus (588) Google Scholar, 7Clarke H. Soneji N. Ko D.T. Yun L. Wijeysundera D.N. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study.BMJ. 2014; 348: g1251Crossref PubMed Scopus (637) Google Scholar, 8Raebel M.A. Newcomer S.R. Reifler L.M. et al.Chronic use of opioid medications before and after bariatric surgery.JAMA. 2013; 310: 1369-1376Crossref PubMed Scopus (171) Google Scholar Recent studies also showed increases in mortality in patients with more than 4 providers and more than 4 pharmacies, and those who use greater than 100 morphine equivalents units per day.9Gwira Baumblatt J.A. Wiedeman C. Dunn J.R. Schaffner W. Paulozzi L.J. Jones T.F. High-risk use by patients prescribed opioids for pain and its role in overdose deaths.JAMA Intern Med. 2014; 174: 796-801Crossref PubMed Scopus (197) Google Scholar Orthopedic surgery patients in particular have been considered to be at a higher risk for developing opioid dependence in the postoperative period.3Jiang X. Orton M. Feng R. et al.Chronic opioid usage in surgical patients in a large academic center.Ann Surg. 2017; 265: 722-727Crossref PubMed Scopus (146) Google Scholar, 4Volkow N.D. McLellan T.A. Cotto J.H. Karithanom M. Weiss S.R.B. Characteristics of opioid prescriptions in 2009.JAMA. 2011; 305: 1299-1301Crossref PubMed Scopus (617) Google Scholar One recent study using insurance company databases reported the prolonged use of prescription opioids after hand surgery.10Johnson S.P. Chung K.C. Zhong L. et al.Risk of prolonged opioid use among opioid-naïve patients following common hand surgery procedures.J Hand Surg Am. 2016; 41: 947-957.e3Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar Although postoperative pain management is imperative in caring for surgical patients, orthopedic surgeons need to use all available tools to limit unnecessary or excessive prescribing of opioids. Even patients who are prescribed opioids for acute postsurgical pain may develop chronic opioid dependence.3Jiang X. Orton M. Feng R. et al.Chronic opioid usage in surgical patients in a large academic center.Ann Surg. 2017; 265: 722-727Crossref PubMed Scopus (146) Google Scholar Several studies assessed the extent to which, in orthopedic surgical patients, preoperative opioid exposure correlates to prolonged use after surgery.10Johnson S.P. Chung K.C. Zhong L. et al.Risk of prolonged opioid use among opioid-naïve patients following common hand surgery procedures.J Hand Surg Am. 2016; 41: 947-957.e3Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar, 11Schoenfeld A.J. Nwosu K. Jiang W. et al.Risk factors for prolonged opioid use following spine surgery, and the association with surgical intensity, among opioid-naive patients.J Bone Joint Surg Am. 2017; 99: 1247-1252Crossref PubMed Scopus (118) Google Scholar, 12Cryar K.A. Hereford T. Edwards P.K. Siegel E. Barnes C.L. Mears S.C. Preoperative smoking and narcotic, benzodiazepine, and tramadol use are risk factors for narcotic use after hip and knee arthroplasty.J Arthroplasty. 2018; 33: 2774-2779Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar In 2001, the Joint Commission on Accreditation of Healthcare Organizations instituted rigorous pain assessment standards that led to pain becoming the fifth vital sign. The Centers for Disease Control13Centers for Disease Control and PreventionNational Center for Injury Prevention and Control, Division of Unintentional Injury Prevention.http://www.cdc.gov/injuryGoogle Scholar reported increasing 10-year trends in national opioid prescribing rates starting in 2006 and peaking in 2012, with more than 225 million prescriptions, or 81.3 prescriptions per 100 persons. The overall national opioid prescribing rate has since declined from 2012 to 2017, and in 2017 the prescribing rate fell to the lowest in 10 years at 58.7 prescriptions per 100 persons. Upper-extremity surgeons need a true understanding of patient need for opioid analgesics to provide pain relief and patient satisfaction without contributing to the national opioid crisis. Rodgers et al5Rodgers J. Cunningham K. Fitzgerald K. Finnerty E. Opioid consumption following outpatient upper extremity surgery.J Hand Surg Am. 2012; 37: 645-650Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar reported that 77% of patients (193) took 15 or fewer opioid analgesics, whereas 45% (113) took fewer than 5 pills and some took none at all after outpatient upper-extremity surgery. They also identified that opioid needs were higher among patients who underwent bony-related procedures (14 pills), lower for soft tissue procedures (9 pills), and lower among Medicare beneficiaries. Kim et al14Kim N. Matzon J.L. Abboudi J. et al.A prospective evaluation of opioid utilization after upper-extremity surgical procedures: identifying consumption patterns and determining prescribing guidelines.J Bone Joint Surg Am. 2016; 98: e89Crossref PubMed Scopus (240) Google Scholar confirmed these results in 1,400 patients who consumed approximately 5 pills after minor soft tissue hand procedures, or 13 to 14 pills for procedures involving bone. Waljee et al15Waljee J. Zhong L. Hou H. Sears E. Brummett C. Chung K. The use of opioid analgesics following common upper extremity surgical procedure: a national, population-based study.Plast Reconstr Surg. 2016; 137: 355e-364eCrossref PubMed Scopus (118) Google Scholar reported that the need for opioid analgesics was closely associated with age, the type of procedure performed, and the preexisting use of opioid medication. Patients with psychosocial stressors, poor coping skills, and preexisting pain syndromes such as fibromyalgia are more likely to consume opioid analgesics after surgery.16Vranceanu A.M. Jupiter J.B. Mudgal C.S. Ring D. Predictors of pain intensity and disability after minor hand surgery.J Hand Surg Am. 2010; 35: 956-960Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar, 17Vranceanu A.M. Bachoura A. Weenig A. Vrahas M. Smith R.M. Ring D. Psychological factors predict disability and pain intensity after skeletal trauma.J Bone Joint Surg Am. 2014; 96: e20Crossref PubMed Scopus (206) Google Scholar, 18Brummett C.M. Janda A.M. Schueller C.M. et al.Survey criteria for fibromyalgia independently predict increased postoperative opioid consumption after lower-extremity joint arthroplasty: a prospective, observational cohort study.Anesthesiology. 2013; 119: 1434-1443Crossref PubMed Google Scholar, 19Janda A.M. As-Sanie S. Rajala B. et al.Fibromyalgia survey criteria are associated with increased postoperative opioid consumption in women undergoing hysterectomy.Anesthesiology. 2015; 122: 1103-1111Crossref PubMed Scopus (80) Google Scholar Chapman et al20Chapman T. Kim N. Maltenfort M. IIyas A. Prospective evaluation of opioid consumption following carpal tunnel release surgery.Hand (N Y). 2017; 12: 39-42Crossref PubMed Scopus (68) Google Scholar prospectively reported that opioid consumption after carpal tunnel release averaged 4.3 pills, with 87% consuming 10 or fewer pills. A total of 41% of patients consumed no opioid at all. The researchers found that older patients took significantly fewer pills compared with younger patients. On average, patients aged 20 to 39 years took 8.13 pills, those aged 40 to 59 years took 4.89 pills, those aged 60 to 79 years took 3.97 pills, and those aged greater than 80 years took only 2.45 pills. Miller et al21Miller A. Kim N. Zmistowski B. IIyas A. Matzon J. Postoperative pain management following carpal tunnel release: a prospective cohort evaluation.Hand (N Y). 2017; 12: 541-545Crossref PubMed Scopus (23) Google Scholar prospectively analyzed the average total pill consumption of an opioid cohort (4.9 pills) and a nonopioid patient cohort (tramadol, 3.3 pills) after carpal tunnel release and found that both groups used less than 5 pills after surgery. O’Neil et al22O’Neil J. Wang M. Kim N. Maltenfort M. IIyas A. Prospective evaluation of opioid consumption after distal radius fracture repair surgery.Am J Orthop (Belle Meade NJ). 2017; 46: E35-E40PubMed Google Scholar evaluated opioid consumption after distal radius fracture–open reduction internal fixation and reported a significant relationship between increasing age and decreasing opioid consumption, as well as increasing opioid consumption with increasing fracture severity, and self-payment/Medicaid payment. Mean opioid consumption (morphine equivalents) was 58.5 mg (range, 0–280 mg), roughly equivalent to 14.6 tablets of oxycodone–acetaminophen 5/325 mg. Zhu et al23Zhu H. Gao Y. Zhang C. Zheng X. A prospective evaluation of patient-reported opioid utilization after nonoperative treatment of fractures and dislocations.J Bone Joint Surg Am. 2018; 100: 1177-1183Crossref PubMed Scopus (6) Google Scholar looked at 1,513 prospective patients treated nonsurgically after fractures and dislocations. They reported opioid consumption in patients with fracture and/or dislocation of the wrist or forearm (9.4 pills for 3.8 days) and the elbow or humerus (9.1 pills for 3.7 days). Patient education can be a useful tool in the effort to diminish the use of opioids after hand surgery. Prospective randomized studies have shown that presurgical counseling and education have resulted in a substantial reduction in postoperative opioid consumption for basic hand surgical procedures (up to two-thirds). Methods introduced by counseling include seeking nonopioid alternatives, defining a finite duration of opioid use, prescribing low-dose quantities, and screening for baseline abuse risk factors.24Alter T. Ilyas A. A prospective randomized study analyzing preoperative opioid counseling in pain management after carpal tunnel release surgery.J Hand Surg Am. 2017; 42: 810-815Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Certainly, surgeon awareness and education can also serve as catalysts to diminish opioid prescription and the potential for abuse. Referencing studies to identify populations most at risk for abuse will target those who would benefit most from a priori counseling.20Chapman T. Kim N. Maltenfort M. IIyas A. Prospective evaluation of opioid consumption following carpal tunnel release surgery.Hand (N Y). 2017; 12: 39-42Crossref PubMed Scopus (68) Google Scholar Ongoing studies indicate that most patients will respond favorably to the opioid education process and wish to minimize opioid prescription in the perioperative setting.25Bargon CA, Zale EL, Magidson J, Chen N, Ring D, Vraceanu AM. Factors associated with patients’ perceived importance of opioid prescribing policies in an orthopedic hand surgery practice [published online ahead of print August 16, 2018]. J Hand Surg Am. https://doi.org/10.1016/j.jhsa.2018.06.118.Google Scholar A number of states have implemented policies to address the opioid epidemic, including drug take-back programs, prescriber education, and prescription drug monitoring programs (PDMPs),26Griggs C.A. Weiner S.G. Feldman J.A. Prescription drug monitoring programs: examining limitations and future approaches.West J Emerg Med. 2015; 16: 67-70Crossref PubMed Scopus (50) Google Scholar which can provide clinicians with information to identify patients who may be diverting medications or abusing them.26Griggs C.A. Weiner S.G. Feldman J.A. Prescription drug monitoring programs: examining limitations and future approaches.West J Emerg Med. 2015; 16: 67-70Crossref PubMed Scopus (50) Google Scholar As of November, 2017, 49 states had an active PDMP, although mandatory use is variable. Prescribers in these states are able to query the online database each time a patient is prescribed a controlled substance; this practice is mandatory in 33 states.27Prescription Drug Monitoring Program Training and Technical Assistance Center2017 Prescription Drug Monitoring Program Introduced and Enacted Legislation and Regulations.http://www.pdmpassist.org/content/statutes-and-regulationsGoogle Scholar In addition, pharmacies can submit data to the state PDMP after dispensing the controlled substance. In 28 states, this is mandated by state law.27Prescription Drug Monitoring Program Training and Technical Assistance Center2017 Prescription Drug Monitoring Program Introduced and Enacted Legislation and Regulations.http://www.pdmpassist.org/content/statutes-and-regulationsGoogle Scholar Databases for many PDMPs have the capacity to share information with other states’ PDMPs, which increases their overall usefulness for clinicians. Recent data from Florida showed a decline in prescription drug overdose deaths and doctor shopping (attempting to obtain narcotics prescriptions from multiple providers) after implementation of the PDMP and pain clinic law.28Johnson H. Paulozzi L. Porucznik C. Mack K. Herter B. Hal Johnson Consulting and Division of Disease Control and Health Promotion, Florida Department of Health. Decline in drug overdose deaths after state policy changes - Florida, 2010-2012.MMWR Morb Mortal Wkly Rep. 2014; 63: 569-574PubMed Google Scholar, 29Electronic-Florida Online Reporting of Controlled Substances Evaluation. Florida PDMP Annual Report, 2012-2013.http://www.floridahealth.gov/reports-and-data/e-forcse/news-reports/_documents/2012-2013pdmp-annual-report.pdfGoogle Scholar Virginia also reported a decrease in doctor shoppers after implementing the PDMPs.30Warner M. Hedegaard H. Chen L. Trends in drug-poisoning deaths: United States, 1999–2012.http://www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htmGoogle Scholar Unfortunately, current evidence to support the effectiveness of PDMPs comes from observational studies or surveys of providers.31Prescription Drug Monitoring Program Center of Excellence at BrandeisBriefing on PDMP effectiveness (2014).http://www.pdmpexcellence.org/sites/all/pdfs/Briefng%20on%20PDMP%20Effectiveness%203rd%20revision.pdfGoogle Scholar Despite the lack of evidence regarding the effectiveness of the websites, the downside and added burden to physicians who are required to use the systems are minimal. The websites are user-friendly and efficient, and it takes only a few minutes to check on patients’ history of controlled substance use. Clarke et al7Clarke H. Soneji N. Ko D.T. Yun L. Wijeysundera D.N. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study.BMJ. 2014; 348: g1251Crossref PubMed Scopus (637) Google Scholar found that 3.1% of nearly 40,000 opioid-naïve patients undergoing elective surgery continued to use opioids more than 3 months after surgery. Risk factors for prolonged use included preoperative benzodiazepine use. Schoenfeld et al11Schoenfeld A.J. Nwosu K. Jiang W. et al.Risk factors for prolonged opioid use following spine surgery, and the association with surgical intensity, among opioid-naive patients.J Bone Joint Surg Am. 2017; 99: 1247-1252Crossref PubMed Scopus (118) Google Scholar found that socioeconomic status and preexisting mental health disorders were associated with prolonged opioid use in patients undergoing spine surgery. In a series of patients undergoing hip and knee arthroplasty, Cryar et al12Cryar K.A. Hereford T. Edwards P.K. Siegel E. Barnes C.L. Mears S.C. Preoperative smoking and narcotic, benzodiazepine, and tramadol use are risk factors for narcotic use after hip and knee arthroplasty.J Arthroplasty. 2018; 33: 2774-2779Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar reported that patients who used benzodiazepines or tramadol before surgery required more narcotics after surgery compared with those who did not use these substances beforehand. Hozack et al (presented at the annual meeting of the American Society for Surgery of the Hand, 2018, Boston, MA) prospectively evaluated opioid use in patients undergoing hand surgical procedures. Patients who had preoperative exposure to benzodiazepines were 1.9 times more likely to fill an opioid prescription after surgery compared with patients with no prior exposure. Similarly, patients with preoperative sedative/hypnotic exposure were 1.9 times more likely to use opioids after surgery compared with patients with no prior exposure. Johnson et al28Johnson H. Paulozzi L. Porucznik C. Mack K. Herter B. Hal Johnson Consulting and Division of Disease Control and Health Promotion, Florida Department of Health. Decline in drug overdose deaths after state policy changes - Florida, 2010-2012.MMWR Morb Mortal Wkly Rep. 2014; 63: 569-574PubMed Google Scholar found that 13% of opioid-naïve patients continued to fill prescriptions more than 3 months after hand surgery. Patients with a history of alcohol abuse, pain diagnosis, or mental health disorders were more likely to use opioids for a prolonged period. Waljee et al15Waljee J. Zhong L. Hou H. Sears E. Brummett C. Chung K. The use of opioid analgesics following common upper extremity surgical procedure: a national, population-based study.Plast Reconstr Surg. 2016; 137: 355e-364eCrossref PubMed Scopus (118) Google Scholar reported that in patients undergoing upper-extremity surgery, patients with previous opioid exposure were more likely to fill a narcotic prescription after surgery, receive refills, and receive longer prescriptions. In a series of patients undergoing distal radius fracture fixation, Teunis et al32Teunis T. Stoop N. Park C.J. Ring D. What factors are associated with a second opioid prescription after treatment of distal radius fractures with a volar locking plate?.Hand (N Y). 2015; 10: 639-648Crossref PubMed Scopus (19) Google Scholar found that among other factors, receiving an opioid prescription within 90 days before surgery was a risk factor for obtaining a second prescription after surgery. In the study by Schoenfeld et al,11Schoenfeld A.J. Nwosu K. Jiang W. et al.Risk factors for prolonged opioid use following spine surgery, and the association with surgical intensity, among opioid-naive patients.J Bone Joint Surg Am. 2017; 99: 1247-1252Crossref PubMed Scopus (118) Google Scholar only 0.1% of opioid-naïve spine patients continued to use opioids more than 6 months after surgery. In a study by Kim et al,33Kim K.Y. Anoushiravani A.A. Chen K.K. Roof M. Long W.J. Schwarzkopf R. Preoperative chronic opioid users in total knee arthroplasty—which patients persistently abuse opiates following surgery?.J Arthroplasty. 2018; 33: 107-112Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar however, 43.4% of chronic opioid users continued to use narcotics 6 months after total knee arthroplasty. In contrast, only 4.9% of patients who had not previously used opioids continued to use them after 6 months. Hozack et al (presented at the annual meeting of the American Society for Surgery of the Hand, 2018, Boston, MA) found that hand surgical patients with prior opioid exposure filled an average of 3.3 prescriptions after surgery, compared with an average of 0.8 for patients without prior exposure. That study also found that 5.5% of opioid-exposed patients continued to fill prescriptions more than 3 months after surgery. Recently, there has been considerable effort in investigating nonopioid analgesics in upper-extremity surgery. Studies demonstrated a reduction in opioid consumption with the use of liposomal bupivacaine in trigger finger release,34Ketonis C. Kim N. Liss F. et al.Wide awake trigger finger release surgery: prospective comparison of lidocaine, Marcaine, and Exparel.Hand (N Y). 2016; 11: 177-183Crossref PubMed Scopus (14) Google Scholar distal radius fracture repair,35Alter T.H. Liss F.E. Ilyas A.M. A prospective randomized study comparing bupivacaine hydrochloride versus bupivacaine liposome for pain management after distal radius fracture repair surgery.J Hand Surg Am. 2017; 42: 1003-1008Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar basal thumb surgery,36Miller A.J. Livesey M. Martin D.P. et al.Thumb basal joint arthroplasty: prospective comparison of perioperative analgesia and opioid consumption.Orthopedics. 2018; 41: e410-e415Crossref PubMed Scopus (3) Google Scholar and shoulder surgery.37Wang K. Zhang H.X. Liposomal bupivacaine versus interscalene nerve block for pain control after total shoulder arthroplasty: a systematic review and meta-analysis.Int J Surg. 2017; 46: 61-70Crossref PubMed Scopus (14) Google Scholar Adams and coworkers38Adams A.J. Buczek M.J. Flynn J.M. Shah A.S. Perioperative ketorolac for supracondylar humerus fracture in children decreases postoperative pain, opioid usage, and length of stay.J Hand Surg Am. 2018; 43: s15-s16Abstract Full Text Full Text PDF Google Scholar showed that adding ketorolac to the pain management regimen in children with supracondylar elbow fractures led to a reduction in both opiate need and the length of hospital stay. Two randomized, double-blinded, prospective studies confirmed that nonopioid medications such as acetaminophen and ibuprofen are as effective as narcotic medications in treating postoperative pain after carpal tunnel and trigger finger surgery.39Thibaudeau S. Gray B.L. Bonilla K. Oduwole S. Bozentka D. Steinberg D. Optimizing postoperative pain control in ambulatory hand surgery—acetaminophen with codeine versus ibuprofen/acetaminophen: a double-blind randomized control trial.J Hand Surg Am. 2018; 43: s6-s7Abstract Full Text Full Text PDF Google Scholar, 40Ilyas A.M. Miller A.J. Graham J. Martin D.P. Matzon J.L. Fighting the “opioid epidemic”: a prospective randomized controlled double-blinded trial comparing acetaminophen, ibuprofen, and oxycodone after hand surgery.J Hand Surg Am. 2018; 43: s6Abstract Full Text Full Text PDF Google Scholar Positive impacts on both opioid prescription patterns and opioid consumption were demonstrated recently using simple educational tools. Dwyer and colleagues41Dwyer C.L. Soong M. Hunter A. Dashe J. Tolo E. Kasparyan G. Prospective evaluation of an opioid reduction protocol in hand surgery.J Hand Surg Am. 2018; 43 (516.e1–522.e1)Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar employed written protocols for opiate prescribers and educational handouts for patients. These 2 interventions led to a 35% to 55% reduction in opiate consumption. Instituting opiate prescription protocols for standard upper-extremity surgeries can lead to a substantial reduction in opioid use.42Earp B.E. Silver J. Mora A.N. Blazar P.E. Implementation of a postoperative opioid prescribing protocol significantly reduces total morphine milligram equivalents prescribed: level 4 evidence.J Hand Surg Am. 2018; 43: S8Abstract Full Text Full Text PDF PubMed Google Scholar, 43Mierisch C. Gaddis A. Apel P.J. Bravo C.J. Dancea H.C. Mierisch C.M. Smaller opioid prescriptions reduce opioid use without decreasing patient satisfaction.J Hand Surg Am. 2018; 43: S21-S22Abstract Full Text Full Text PDF Google Scholar In addition to written educational handouts to patients, preoperative counseling has been shown to reduce narcotic consumption after surgery.44Ilyas A. Alter T. A prospective randomized study analyzing the effect of pre-operative opioid counseling on post-operative opioid consumption after hand surgery.J Hand Surg Am. 2018; 43: s20Abstract Full Text Full Text PDF Google Scholar The failure of proper opioid disposal and unsecure storage are critical components in the opioid epidemic.45Bartels K. Mayes L.M. Dingmann C. Bullard K.J. Hopfer C.J. Binswanger I.A. Opioid use and storage patterns by patients after hospital discharge following surgery.PLoS One. 2016; 11: e0147972Crossref PubMed Scopus (268) Google Scholar, 46Bicket M.C. Long J.J. Pronovost P.J. Alexander G.C. Wu C.L. Prescription opioid analgesics commonly unused after surgery: a systematic review.JAMA Surg. 2017; 152: 1066-1071Crossref PubMed Scopus (537) Google Scholar When not disposed of, opioids can be accessible to individuals who are prone to opioid abuse. Bicket and colleagues46Bicket M.C. Long J.J. Pronovost P.J. Alexander G.C. Wu C.L. Prescription opioid analgesics commonly unused after surgery: a systematic review.JAMA Surg. 2017; 152: 1066-1071Crossref PubMed Scopus (537) Google Scholar reported that after joint and spine surgery, most patients did not dispose of their unused medication properly and were unaware of effective mechanisms to do so. Whereas recent work in the orthopedic literature focused on decreasing the amount of medication prescribed, other medical disciplines also focused on the proper disposal of unused narcotic medications. For this reason, novel techniques have been employed to dispose of dangerous medication properly in an environmentally safe fashion. Maughan and colleagues47Maughan B.C. Hersh E.V. Shofer F.S. et al.Unused opioid analgesics and drug disposal following outpatient dental surgery: a randomized controlled trial.Drug Alcohol Depend. 2016; 168: 328-334Crossref PubMed Scopus (150) Google Scholar reported that informing patients about pharmacy-based opioid disposal programs led to a 22% increase in the proportion of patients who disposed or intended to dispose of unused opioids after dental surgery. In a comprehensive report of the literature by Bicket et al in the Journal of the American Medical Association, all reviewed studies demonstrated low rates of opioid disposal. Gao et al48Gao X. Bakshi P. Sunkara Ganti S. et al.Evaluation of an activated carbon-based deactivation system for the disposal of highly abused opioid medications.Drug Dev Ind Pharm. 2018; 44: 125-134Crossref PubMed Scopus (8) Google Scholar employed a new disposal mechanism. That group studied the effectiveness of disposing of opioid medications by exposing them to granular carbon in the form of a pouch. The group found that 99% of drugs were deactivated after 28 days in the pouch. This was an effective means of environmentally safely disposing of opioids, which can be readily and easily available to patients. Much of the published data on opioid consumption in hand surgery and orthopedics in general are derived from studies evaluating large insurance databases. Although it may seem simple to derive large pools of data for research regarding the prescription, distribution, consumption, and disposal of opioids, information stemming from insurance databases may generate confounding data. Patients receiving Medicare, Medicaid, and workers’ compensation are omitted from these databases, and therefore the complexities of these populations and their contribution to opioid use demographics is often excluded. In addition, these databases are often based on Current Procedural Terminology or International Statistical Classification of Diseases and Related Health Problems codes and do not include patient-to-patient variability or allow a differentiation among conflicting data from varying specialties using the same codes. Future work should focus on educating both medical professionals and patients regarding the dangers of continued opioid use and misuse. Patient and physician education, a better understanding of opioid use patterns, multimodal pain management modalities, and monitoring of patient opioid use employing states’ PDMP websites should be implemented together with improving patient care to limit the ravaging effects of the opioid epidemic. 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• W2904650830 title "What’s New in the Battle Against the Opioid Crisis in Hand Surgery: A Review" @default.
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