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