As part of ASHT’s opioid crisis campaign, the ASHT Practice Division conducted an interview of a fellowship-trained hand surgeon, Dr. Philip To, practicing in Scottsdale, AZ, to provide insight into this crisis, the effect on post-surgical care and how the practicing OT or PT hand therapist may better partner in combating the epidemic at hand.
From your perspective as a hand surgeon, are you seeing proof of an opioid crisis?
Absolutely. During my residency from 2008-2013, I saw maybe 1-2 heroin-related abscesses. During my fellowship, there was a patient every night who had some type of heroin-related infection in their upper extremity. It was people of all walks of life and all ages.
What kind of impact has the potential for opioid addiction among your patients had on your practice?
As the awareness has vastly improved, there is much more of an emphasis on minimizing opioids. There are new studies looking at the duration and number of pills taken post operatively for hand surgery. I have been trending to minimize all narcotics.
Have you found empirically that your patients, especially those post-operatively, are inherently capable of effective pain control?
I do believe certain people have better abilities to cope with pain. I also believe education on the pain meds and dangers of narcotics does a lot in helping patients minimize narcotics post-operatively. My patients over 75 do very well with no narcotics.
Have you found evidence of alternative, non-opioid medication as effective in assisting patients in pain control?
Most patients can do well with just Tylenol and NSAIDs for pain control. I always tell them to start with that. Many patients over 65 have ulcers, so I always counsel them on the dangers of ulcers and NSAIDs. I do believe hand therapy is effective in decreasing pain for patients with more involved procedures such as LRTI. There are newer studies that show the efficacy of pain control with non-opioid medications after orthopedic procedures.
What is your proposed strategy for curbing our current opioid epidemic?
I try to encourage each and every patient to stay away from narcotics. For my small soft tissue procedures, I will recommend no opioids. For the larger procedures, I will only prescribe five days of hydrocodone. I very rarely refill pain meds after surgery as I will encourage them to transition to NSAIDs and Tylenol.
How do you feel the role of the hand therapist may assist in this strategy?
Hand therapy is key in minimizing pain after surgery. Therapy not only improves range of motion and swelling, but also a patient’s psyche. Therapists see the patient more than the surgeon and play an integral part of the care process. Pain perception is physical and mental. We are also seeing data on how aspects of the psyche can effect pain. Behind a good hand surgeon is a better hand therapist.