Provider-patient communication one key to reining in crisis
"Although the United States represents less than 5 percent of the world's population, it consumes about 80 percent of all the world's opioid production," said Asif Ilyas, MD, FACS. "And when surveyed, 80 percent of heroin users said they started abuse with prescription opioids, then turned to heroin because it was cheaper and easier to get."

Dr. Ilyas made his remarks during the 2017 annual meeting of the American Society for Surgery of the Hand where he presented findings from his study, "A Prospective Randomized Study Analyzing the Effect of Pre-Operative Opioid Counseling on Opioid Consumption after Carpal Tunnel Release Surgery."

He noted that multiple pressures have contributed to the opioid epidemic in this country, including the following:

• Patient factors such as high rates of abuse with substances other than opioids, concomitant, predisposing psychiatric conditions, and unrealistic expectations
• Societal factors such as direct-to-consumer and physician marketing of opioids, expectations of aggressive pain management, and the promotion of pain as the 5th vital sign
• Physician factors such as overprescribing or a lack of communication with patients regarding opioid risks

Dr. Ilyas also pointed to a recent study, published in The Journal of the American Medical Association that reviewed data on 36,177 opioid-naïve surgical patients. It found that approximately 6 percent of patients still reported taking opioids 6 months postoperatively, with no significant difference whether they had undergone major or minor procedures.

Formal counseling associated with decreased opioid consumption
According to Dr. Ilyas, several studies have suggested that preoperative opioid counseling may decrease a patient's postoperative opioid consumption. "The purpose of our study, therefore," he said, "was to compare pain experience and opioid consumption after carpal tunnel release (CTR) surgery among a group of patients who received formal, preoperative opioid counseling and a group that did not receive any formal counseling."

Dr. Ilyas and his colleagues conducted a prospective trial of 40 patients who were randomized to receive either formal preoperative opioid counseling or no counseling. The average age was 61 years in the counseling group (n = 20, 11 females) and 62 years in the no-counseling group (n = 20, 14 females).

All procedures were performed with the same mini-open CTR surgical technique and the same number and type of opioids were prescribed after each surgery. The researchers recorded daily opioid pill consumption, pain levels, and any adverse reactions.

All procedures were performed under local anesthesia alone, with 10 mL to 15 mL of 1 percent lidocaine with epinephrine and 1 mL of 8.4 percent bicarbonate. Following surgery, all patients were prescribed 10 pills of acetaminophen No. 3 (325 mg of acetaminophen and 30 mg of codeine).

Patient counseling sessions were conducted using a single-page outline based on information provided by the Pennsylvania Orthopaedic Society. It consisted of information on the opioid crisis, along with the following five recommendations:

1. Try using nonopioid therapy before using the prescribed opioids if possible.
2. For this procedure, you should not need opioids beyond 3 days postoperative.
3. The lowest dose opioid will be prescribed.
4. Do not mix opioids with other pain medications or alcohol.
5. Notify the surgeon if you are currently taking opioids or have had issues with them in the past.

Overall, patients in the counseling group consumed two-thirds fewer prescribed opioid pills (1.4 pills) compared to the no-counseling group (4.2 pills), as identified by the first postoperative visit. The difference was significant on the day of surgery and on the first postoperative day. Further, 12 patients in the counseling group and 4 patients in the no-counseling group consumed zero opioid pills. The researchers found no significant differences across cohorts in pain level experience at any time point.

Regarding the use of alternative analgesics, on the day of surgery, 12 patients in the counseling group and 7 patients in the no-counseling group consumed a nonprescription painkiller preferentially over their prescribed opioid. On postoperative day 1, 15 patients in the counseling group and 10 patients in the no-counseling group consumed a nonprescription painkiller. On postoperative day 2, the numbers fell to 10 patients and 8 patients, respectively.

The researchers noted no major adverse reactions in either group. One patient in the no-counseling group reported constipation.

Strengths and limitations
"The study was designed only to compare opioid consumption and pain experience following CTR surgery in patients with and without preoperative counseling," said Dr. Ilyas. "Its strength lies in its prospective and randomized nature, same surgery performed by the same surgeon, consecutive patient series, and 100 percent response rate.

"Limitations include the fact that the data is based solely on the experience of a single surgeon at one institution," he continued. "We only evaluated acetaminophen with codeine, and so the findings may not be applicable to all opioids. Finally, there may be some recall bias in which patients misreported their actual pain experience or opioid pill consumption. And our study did not measure overall satisfaction with pain management, so we couldn't determine if counseling altered patient satisfaction levels.

"Based on our findings, we recommend that surgeons consider routine preoperative patient counseling to help minimize opioid use. Additionally, we recommend prescribing no more than 5 to 10 opioid pills after CTR surgery."

Dr. Ilyas' coauthor is Todd H. Alter, BS. Findings from the study were published in The Journal of Hand Surgery (October 2017).

Peter Pollack is the electronic content specialist for AAOS Now. He can be reached at ppollack@aaos.org.

Bottom Line

• Researchers conducted a prospective, randomized trial of 40 patients undergoing CTR by a single surgeon.
• The purpose was to compare pain experience and opioid consumption in patients who received preoperative opioid counseling with patients who did not receive counseling.
• Preoperative counseling was associated with a two-thirds reduction in opioid use at all time points.
• No significant differences in pain level experience across cohorts were found.