Creating New Ways of Thinking About Postoperative Opioid Prescribing

A poster at this year’s ASPS Surgical Conference, "A Novel Postoperative Educational Intervention Entitled The Ten Principles of Opioid Prescribing in Foot and Ankle Surgery: A 4-Year Pre-Post, Mixed Methods Mega-Study," examined how such an educational guide could impact prescribing practice.1 Due to the opioid reservoir phenomenon related to unused prescription pills and significant variation in prescribing habits, this research team evaluated the value of an educational outreach option.

Brandon M. Brooks, DPM, MPH, FASPS, FACPM, DABPM CAQPS, corresponding author of the study, shared that he was inspired by a personal tragedy to work towards solutions in this area.

“My sister Britney passed away from opioid overdose,” he said. “I do research on opioids in her memory. When I became the AMPA’s 6th public health fellow at the Geisel School of Medicine at Dartmouth College in Hanover, NH, I was tasked with completing opioid-related research. This fellowship is unique as it is funded by the American Podiatric Medical Association and comes with the opportunity to earn a master’s degree from an Ivy League medical school. While at Dartmouth, I completed 10 studies which became the 10 principles in this larger study.”  

Details on the Study

Using a mixed methods approach and a before-after study design, the team emailed questionnaires and interviewed US podiatric surgeons, eventually targeting residents for the educational intervention. After a targeted survey of residents, they created the opioid prescribing guide, which they distributed to podiatric residents via email and at several regional podiatry conferences in Fall 2022. The next spring, they conducted another repeat survey of residents and then analyzed the differences in all 3 survey groups. Essentially, three groups of residents reported what they prescribe for a bunionectomy.

Group A represented residents in 2020, pre-pandemic/lockdown AND pre-educational intervention. Groups B and C consisted of residents in the same residency year (2022-2023), pre- and post-intervention, respectively. After a Mann-Whitney U Test, group C revealed a statistically significant mean reduction of 5 opioid dosage units at the time of surgery. The authors also noted that the group C residents more often reported supplementing their prescribing with NSAIDs compared to group B. As these prescribing paradigms are often developed during one’s residency, over 95% of interviewees supported a mandatory pain management rotation during their training. While MDs and DOs in surgical residencies complete pain management rotations, CPME doesn’t mandate this for podiatry residencies.

Dr. Brooks pointed out the qualitative components of the study, which he found particularly interesting:  

1. Prescribing habits begin in residency.

2. Most DPMs are not aware to what our professional societies and organizations are doing to help combat the opioid epidemic.  

3. Most DPMs favor loose guidelines over burdensome and rigid regulations.

“These qualitative findings are what informed us to create the ‘Ten principles of Opioid Prescribing in Foot and Ankle Surgery,’” he explained.

Moving Forward

Dr. Brooks stressed that growth is key for clinicians in this area. “Everyone’s prescribing practice can continue to evolve and be guided by evidenced-based medicine,” he said. “DPMs interested in checking out our educational intervention need only to use their smart phones to scan this QR code. Finally, as a profession, we can make a huge difference.”

References

1. Brooks BM, Ryans CP, Brooks BM, et al. A Novel Postoperative Educational Intervention Entitled The Ten Principles of Opioid Prescribing in Foot and Ankle Surgery: A 4-Year Pre-Post, Mixed Methods Mega-Study. Poster presented at the American Society of Podiatric Surgeons Annual Surgical Conference. New Orleans, LA; October 2023.