Fingertips Reducing Opioid Use in Musculoskeletal Patients ORRIN

Fingertips & Reducing Opioid Use in Musculoskeletal Patients ORRIN FRANKO ORTHOPEDIC & HAND SPECIALIST

Disclosures Owner/Founder: www. Top. Ortho. Apps. com Owner/Founder: www. Surgi. Survey. com No relevant financial disclosures related to the topic of this presentation.

Orrin I. Franko, MD

Fingertips Open fractures (by definition) Ancef Reduce + Tetanus nail avulsions Sometimes Always: Often salvageable… sometimes not Block, Reduce, and Examine (*tips and tricks) forgotten, overlooked, or minimized

Step 1… Block the finger 1% lido +/- epi 2 -3 cc typically sufficient 25 g needle SIMPLE Technique Single Subcutaneous Injection Middle in the of the Proximal Phalanx with Lidocaine and Epinephrine

Step 2… Exam, Image and Reduce Look for avulsed nail plates Nail bed lacerations (open fractures) Exposed tendons Dislocated joints (DIP, PIP, MCP)

Step 3… Fix, or Call a specialist Suture with CHROMIC GUT Typically size 4 -0 or 5 -0 Nail plates need to be removed to repair nailbed lacerations PIP reductions should be easy Temporization: Wrap with moist dressing (xeroform), gauze, and moderate compression (ACE or Coban)

Newest Fingertip Guidelines…

Example Outcomes:

Newest Fingertip Guidelines… www. ebhmc. com/ER

Reducing Opioid Use in Musculoskeletal Patients 1990: 4 tons 2009: 39 tons v Patients want to have little postop pain v Veterans Administration 1999 “fifth vital sign” v JCAHO 2001– rigorous pain standards 99% used inopioids the US v Physicians responded by prescribing

Opioid Epidemic v Patients want to have little postop pain v International Association for the Study of Pain (IASP) v Veterans Administration 1999 “fifth vital sign” v JCAHO 2001– rigorous pain standards v Physicians responded by prescribing opioids v Opioid Epidemic v Hydrocodone (Vicodin) most widely prescribed drug in the US v 100 million prescriptions per year 2007 Legal prescription opioids kill more Americans than heroin or cocaine (CDC data)

Introduction

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Opioid Consumption Following Outpatient Upper Extremity Surgery Journal of Hand Surgery April 2012 Rodgers, et al. • • Five-member hand surgery group Ten month period, outpatient surgery 287 patients agreed to participate Contacted between 7 -14 days post op • • 250 completed the study 76% soft tissue, 24% bone procedures 92% satisfied with pain management Patients given 30 opioid pills

45% took 5 pills or less Some took none Total unused pills: 4, 639 79% were leftover California: 3, 039 orthopedic surgeons 3, 382, 407 unused pills

Honduras – April 2016

Europe

What about in the Hospital? 2017

NSAID + Tylenol Oxy + Tylenol Hydro + Tylenol Codeine + Tylenol

My Experience Started practice in Sept 2016 and gave Rx how I was “trained” Norco 5 mg with every surgery #10 -15 for carpal tunnel/trigger finger #20 -40 for bone procedures (distal radius, finger fractures) Often #20 -30 for fractures not requiring surgery Signed 5 -10 prescriptions each week Signed 1 -2 refill requests each week

Summer 2017 Started reading the current literature in depth Adopted a protocol created by another hand surgeon Modified our patient education materials Created an Epic Smartphrase Effect: Currently hand out 1 -2 opioid prescriptions per week (75% reduction) Almost ZERO refill requests (90% reduction) Patients are just as satisfied Patients occasionally THANK ME for not giving them opioids

Pre-Op Email to all patients

www. EBHMC. com/pain

(Watch this video) https: //www. youtube. com/watch? v=Tt 52 q. S 5 Zttk#action=share

Hand-outs:

Results for EBHMC (Updated 1/19)

Epic Smartphrase

Nursing Education Pain is Normal Worst pain is in first 24 hours Reduces by 50% after 48 hours After 72 hrs it should be manageable *Don’t use the pain scale (if possible) Encourage distractions Talk to friends/family Walk around the hospital, cafeteria, go outside Play games / watch sports Breakthrough medications are strictly for Assistance with sleep Pre-/Post-therapy exacerbation

Summary Non-opioids are effective and safe Reduced dependence/addiction Improves pain management and patient satisfaction Requires re-educating surgeons, hospitalists, nurses and patients Encourage distractions, activity, and mobility