Attitudes and Knowledge Regarding Pain Management and Addiction in Massachusetts: A Mixed Methods Study on Podiatric Residents.

BACKGROUND: The opioid epidemic has hit disastrous levels across the United States. Many attempts have been made to counteract this, including policy changes and modification of provider and patient behavior. The purpose of this study was to understand the current state of podiatric residents' knowledge regarding pain management and addiction. METHODS: This study used mixed quantitative-qualitative methods. Two focus groups were conducted with two podiatric residency programs to understand current issues and inform the creation of a survey. A 30-question survey was created and peer reviewed to assess general pain management knowledge, levels of confidence in pain management and addiction, and areas for improvement. RESULTS: Pain management education in podiatry is mainly focused on opioids. These concepts are often taught in a nonstandardized method, which does not often include nonopioid alternatives. Knowledge of risk factors for addiction was lacking, whereas knowledge of behaviors concerning for addiction was more bountiful. Thirty-three surveys were completed of a possible 39. A knowledge score was created from eight survey questions for a total of 10 points, with an average score of 4.61. There was no statistical difference between those with and without a pain management rotation. Nearly all residents felt comfortable managing surgical pain. The residents are "never" or "only occasionally" inquiring about risk factors for addiction. Questions asked also suggest that the residents are not thinking about their role within the opioid epidemic. CONCLUSIONS: As the opioid epidemic grows, it is imperative to examine the causes and solutions to the problem. Focusing efforts on educating resident physicians is one method to address the issue. The results of this study show that pain management basics need to be reinforced and more time must be spent emphasizing the importance of thorough patient histories and educating patients when prescribing pain medication.

Opioid prescribing habits of podiatric surgeons following elective foot and ankle surgery.

Prescription of opioids following surgery is commonplace in the United States, but with that has come increases in misuse, overdose and death. Evaluating prescribing habits in efforts to reduce the opioid epidemic is becoming more frequent. The purpose of the present study was to examine the self-reported practices of podiatric surgeons regarding their methods of post-operative pain management in adult, sensate patients, as well as assessing the frequency of use of adjunctive pain control modalities. A survey was created and distributed to Podiatric Surgeons electronically, across the United States. Results of this study show that Podiatric Surgeons prescribe hydrocodone/acetaminophen most commonly after surgery, with most prescribing opioids for less than 2 weeks. With regards to adjunctive pain management, two-thirds of respondents use regional anesthesia blocks, with only 13% using post-anesthesia delivery devices (PADD). Interestingly, those using PADDs prescribed significantly more opioids at the first prescription and were more likely to refill the prescription. Podiatric Surgeons are concerned with various negative outcomes for their patients when taking opioids, including addiction, non-adherence, and motor vehicle accidents. Podiatric Surgeons are less concerned about negative outcomes for themselves when prescribing opioids. This study is in agreement with previously published studies in other medical specialties regarding opioid prescribing habits and concerns. However, further research is needed to fully understand the role PADDs and regional anesthesia blocks play in reducing the amount of opioids prescribed following surgery. The Opioid Epidemic in the United States is multi-faceted, but over-prescription by providers is part of it. Continuing to assess and understand how opioids are prescribed will be paramount to curb the epidemic.

Pernio-Induced Toe Pain in the Setting of Onychocryptosis: A Case Report.

Pernio is an inflammatory condition of the skin associated with cold exposure. The dermatologic manifestations may vary, and this entity is frequently misdiagnosed. Its association with systemic disease underscores the importance of accurate diagnosis. The authors describe a case report in which a patient who, after initially presenting with a complaint of pain and an ingrown toenail, was eventually diagnosed with pernio as well.

A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery.

OBJECTIVE: The aim of this study was to determine the bleeding risks associated with single (aspirin) and dual (aspirin + clopidogrel) antiplatelet therapy (DAPT) versus placebo or no treatment in adults undergoing noncardiac surgery. SUMMARY OF BACKGROUND DATA: The impact of antiplatelet therapy on bleeding during noncardiac surgery remains controversial. A meta-analysis was performed to examine the risk associated with single and DAPT. METHODS: A systematic review of antiplatelet therapy, noncardiac surgery, and perioperative bleeding was performed. Peer-reviewed sources and meeting abstracts from relevant societies were queried. Studies without a control group, or those that only examined patients with coronary stents, were excluded. Primary endpoints were transfusion and reintervention for bleeding. RESULTS: Of 11,592 references, 46 studies met inclusion criteria. In a meta-analysis of >30,000 patients, the relative risk (RR) of transfusion versus control was 1.14 [95% confidence interval (CI) 1.03-1.26, P = 0.009] for aspirin, and 1.33 (1.15-1.55, P = 0.001) for DAPT. Clopidogrel had an elevated risk, but data were too heterogeneous to analyze. The RR of bleeding requiring reintervention was not significantly higher for any agent compared to control [RR 0.96 (0.76-1.22, P = 0.76) for aspirin, 1.84 (0.87-3.87, P = 0.11) for clopidogrel, and 1.51 (0.92-2.49, P = 0.1) for DAPT]. Subanalysis of thoracic and abdominal procedures was similar. There was no difference in RR for myocardial infarction [1.06 (0.79-1.43)], stroke [0.97 (0.71-1.33)], or mortality [0.97 (0.87-1.1)]. CONCLUSIONS: Antiplatelet therapy at the time of noncardiac surgery confers minimal bleeding risk with no difference in thrombotic complications. In many cases, it is safe to continue antiplatelet therapy in patients with important indications for their use.

Chondroid Syringoma.

Chondroid syringoma is a cutaneous sweat gland tumor. Despite its relative rarity, a benign and malignant variant have been described. We present a case report of chondroid syringoma of the foot in a healthy patient. Definitive diagnosis required histopathologic examination, while treatment included wide resection. Surgeons who are presented with a painless, solid nodule in the lower extremities should be cognizant of this neoplasm. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case report.