By Greg Askins, MD

My interest in opioid management was peaked after my one son underwent an ACL reconstruction with a central third patellar tendon autograft. He was prescribed 60 oxycodone tabs, but only took 1 after the procedure. My other son underwent an arthroscopic Bankart repair and again was prescribed 60 Oxycodone tabs. He only took 1-2 tabs before switching to over-the-counter pain meds. This made me wonder if I had a good handle on what my patients required for pain meds following common hand procedures. After attending Dr. Kalliainen’s ASSH instructional course on opioid management several years ago, we looked at 2 months’ experience at our orthopedic/plastic surgery ambulatory surgery center for narcotic prescribing. Three years ago, we surveyed patients on how much pain medication they took over the first 7 days after surgery. I would routinely prescribe 10 hydrocodone tablets after a CTR. On the average, my patients would take 2 following surgery. My partner, who also performs an open CTR under local MAC anesthesia, would routinely prescribe 20 hydrocodone. His patients would take an average of 4 tabs after surgery.  It’s as if patients thought they were doing well only taking 20% of what was prescribed following surgery. Most of my patients felt that they did not need anything other than over-the-counter meds after surgery. Based upon that experience, I let patients know that they will not likely need any narcotics after a CTR. I now write a prescription for about half of my patients following a CTR and only for 4-5 tablets. I’ve yet to refill a script, and the vast majority do not request a script when I operate on the other side. I take a similar approach for trigger fingers and operative Dupuytrens, where more often than not, patients have not required more than over-the-counter pain meds.

Over the 2 months that we monitored pain medication prescriptions, scripts for a total of 11908 pills were given to patients following the gamut of procedures. 4795 pills were consumed, leaving 7113 that had the potential to be diverted. Deaths from drug overdoses in Maine increased from 7 in 2011 to 418 in 2017. As a consequence of the opioid epidemic, the state of Maine has intervened with mandates requiring physicians to check the PMP (prescription monitoring program) whenever a new narcotic script is written for a patient. Fines have been imposed for not checking.  Prescribing limits were placed limiting a 7-day supply for acute pain, and not to exceed 100 morphine milligram equivalents for a 24-hour period. The PMP program audits our prescribing practice quarterly with comparison information within your specialty.

Fortunately, there is enough information that surgeons can reasonably prescribe less opioids following procedures and stay within the guidelines outlined above. Hopefully more studies will be forthcoming on prescription management following upper extremity procedures.