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We Are on the Front Lines

By Benjamin R. Graves, MD

Whether we’re aware of it or not, Hand and Upper Extremity surgeons are on the front line of the opioid crisis.  As practitioners of musculoskeletal medicine, we aim to improve our patient’s quality of life with surgery, and occasionally, prescriptions for pain medications.  During the past few years a wave of abuse and addiction of opioid medication has swept across the United States, affecting all ages and socioeconomic groups.  In response to this epidemic, many states have passed new legislation to help curb abuse and addiction.  These laws limit the allowable quantity of opioids and number of refills that can be prescribed, which can be helpful when setting limitations for opioid pain medications with patients.

Like most of us, I have had to adapt my practice as a result of the opioid crisis.  Here are a few strategies I have embraced to help navigate the new opioid medication prescribing environment:

  • Have a clear and concise narcotic pain medication protocol and discuss this with the patient before surgery. This practice has been shown to reduce opioid pills consumed after carpal tunnel release It has also been my experience that post-operative pain control is much harder to discuss after surgery than it is before surgery.  Including a clear, easy to understand pain medication protocol as part of your pre-operative risk and benefits counseling will help establish well-defined boundaries early on and will ensure the patient understands how their pain will be managed after surgery.
  • Prescribe non-opioid medications when possible. A recent study published in the Journal of Hand Surgery2 showed no difference between acetaminophen, ibuprofen, and oxycodone for post-operative pain control after carpal tunnel release.
  • If opioids are required, wean to a less-potent medication with each refill when possible. This can help make the transition from narcotic medications to non-narcotic medications less onerous for the patient.
  • Check before you prescribe. Online databases have revolutionized our ability to stay ahead of opioid-seeking behavior in the clinic setting. Checking the prescription medication history of our patients before filling an opioid prescription lets us know what other prescribers have written for our patients.  Checking this activity before prescribing is becoming a legal requirement in many states.  One such prescription monitoring solution, currently available in 42 states, is PMP AwaRxE

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I keep this website open while seeing patients in clinic and check the database before writing opioid prescriptions.

With awareness of the issue, and diligence with prescribing, Hand and Upper Extremity surgeons can continue to care for our patients while helping prevent abuse and addiction.


  • Alter TH, Ilyas AM. A Prospective Randomized Study Analyzing Preoperative Opioid Counseling in Pain Management After Carpal Tunnel Release Surgery.  J Hand Surg Am. 2017;42(10):810-815.
  • Ilyas AM, Miller AJ, Graham JG, Matzon JL. Pain Management After Carpal Tunnel Release Surgery: A Prospective Randomized Double-Blinded Trial Comparing Acetaminophen, Ibuprofen, and Oxycodone. J Hand Surg Am. 2018;43(10):913-919.

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