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What’s New in UE Care and Best Practice
Jenna Godfrey, MD
Hand Surgeon
Urgent and Critically Relevant in Orthopedic UE Management
Disclosure
I have no financial disclosures.
Dreamland by Sam Quinones
Oregon.gov
2019 Q2: 763,424
2017: 944Hospitalizations
2017: 287 Deaths
• 209.5 million opioid prescriptions dispensed btw 7/2016- 6/2018
• Most common prescribers
• Internal Medicine 16.4%
• Family Medicine 10.3%
• Orthopedics 2.9%
• 438.7 average prescriptions per ORTHOPEDISTS (average overall 215/provider!)
Opioid Prescribing in Orthopedic Surgery• 60% of patients undergoing elective procedures have left over narcotic medications• Only 9% dispose of them properly
• 2-13% opioid naïve pts will continue to use at 90 days post op
• Pts who use opioids pre op are SIG more likely to continue post op
Fortunately….
•Pt edu on post op pain management decrease opioid use without decreasing ptsatisfaction score
•1 hour physician targeted opioid education can reduce MME prescribed by 53%
Slocum Opioid JC Oct 2018
• 2 hr multi specialty JC
•Ortho lit review of the newest post op pain management recommendations
• Subspecialty groups used consensus building to create guidelines for most common procedures
•Goal: standardized prescribing habits, maintain good pain control, reduced number of unused pills
Representative Procedure
Max Discharge Script
Max Refill #1(should taper from discharge
script)
Max Refill #2(should taper from Refill #1
script)
Maximum number of weeks which we will fill opioid prescriptions*
Trigger Finger or DeQuervains
Norco 5, 1-2, q4-6, #5 OR
Oxy 5, 1, q4-6, #3
Patient must be seen to obtain any refills.
No refill. No refill.
Soft tissueECTR/CTR/Tendon repair
Norco 5, 1-2, q4-6, #15OR
Oxy 5, 1, q4-6, #10
Patient must be seen to obtain any refills.
No refill. No refill.
Finger/ MC fracture
Norco 5, 1-2, q4-6, #30OR
Oxy 5, 1, q4-6, #15
Norco 5, 1-2, q4-6, #10OR
Oxy 5, 1, q4-6, #5
Norco 5, 1, q4-6, #5OR
Oxy 5, 1, q4-6, #3
2 weeks
MCP fusion/ CMC arthroplasty
Norco 5, 1-2, q4-6, #30OR
Oxy 5, 1, q4-6, #20
Norco 5, 1-2, q4-6, #10OR
Oxy 5, 1, q4-6, #5
Norco 5, 1, q4-6, #5OR
Oxy 5, 1, q4-6, #3
2 weeks
Distal radius fracture non-op
Norco 5, 1-2, q4-6, #15OR
Oxy 5, 1, q4-6, #10
2 weeks
Distal radius fracture ORIF
Norco 5, 1-2, q4-6, #30OR
Oxy 5, 1, q4-6, #20
Norco 5, 1-2, q4-6, #15OR
Oxy 5, 1, q4-6, #10
Norco 5, 1, q4-6, #5OR
Oxy 5, 1, q4-6, #3
2 weeks
Wrist partial or full fusion / PRC
Norco 5, 1-2, q4-6, #30OR
Oxy 5, 1, q4-6, #20
Norco 5, 1-2, q4-6, #15OR
Oxy 5, 1, q4-6, #10
Norco 5, 1, q4-6, #5OR
Oxy 5, 1, q4-6, #3
2 weeks
Opioid naïve patients (no opioids in past 30 days) – All quantities based on 7 day (+ 2 day refill buffer)
Dupuytren’s
• Celtic descent –English/Irish/Scottish/Scandinavian
• Increased severity:• Immediate family member with disease
• Onset
• 47% recurrence at 5yr in successfully treated joints
• More common to recur in PIP contracture than MP
Xiaflex indications
• Historical surgical indications: 30 degree joint contracture
• Palpable cord
• BUT:
• Refer any patient with progressive Dupuytren’s with any contracture
• PIP contracture HARDER TO TREAT
References
• Quinones, Sam. Dream Land. Bloomsbury Press. 2015
• Oregon.gov: Opioid Overdose and Misuse. https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Pages/data.aspx
• Lane County Oregon. 2019 Point in time count. www.lanecounty/HomelessCount
• Guy, GP and Zhang, K. Opioid Prescribing by Specialty and Volume in the U.S. Am. J. Prev. Med. 2018 Nov. e 153-155.
• Stepan, JG et al. Opioid Prescriber Education and Guidelines for Ambulatory Upper-Extremity Surgery: Evaluation of an Institutional Protocol. JHS 2019 Feb 44(2):129-36.
• Sabatino, MJ et al. Excess Opioid Medication and Variation in Prescribing Patterns Following Common Orthopedic Procedures. JBJS 2018;100: 180-8.
• Dwyer, CL et al. Prospective Evaluation of an Opioid Reduction Protocol in Hand Surgery. JSH 2018;43:516-22.
• Peimer, C et al. Dupuytren’s contracture recurrence following treatment with collagenase clostridium histolyticum (CORDLESS STUDY) at 5 years. JHS. 2015 1597-1605.
https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Pages/data.aspxhttp://www.lanecounty/HomelessCount