Opioid Prescribing in Podiatry: Pearls, Pitfalls, and Practical Updates

In this episode, Savannah Santiago, DPM, shares practical guidance on responsible opioid prescribing, common pitfalls, and evidence-based approaches that help podiatrists optimize pain control while minimizing risk – all from her session at the APMA National.

Key Takeaways

• Individualized prescribing leads to better outcomes. Postoperative pain management should be tailored to each patient's procedure, medical history, opioid exposure, and risk factors rather than relying on standardized prescribing habits.
• Multimodal pain management can reduce opioid use. Regional nerve blocks, NSAIDs, elevation, icing, edema control, and comprehensive patient education all play important roles in minimizing opioid requirements after foot and ankle surgery.
• Documentation and patient counseling are essential. Thorough preoperative discussions, clear written postoperative instructions, coordination with pain management when appropriate, and careful documentation help improve patient safety while supporting responsible opioid stewardship and regulatory compliance.

Transcript

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text. 

Jennifer Spector, DPM: Hello and welcome back to Podiatry Today Podcast. I'm your host, Dr. Jennifer Spector, the Associate Editorial Director for Podiatry Today. Opioid prescribing remains one of the most important and closely scrutinized aspects of patient care. While awareness of opioid-related risks has grown substantially, clinicians still continue to face challenges in balancing effective post-op pain management and responsible prescribing practices. Joining me today to talk about a session that she'll be participating in at the APMA National is Dr. Savannah Santiago. Dr. Santiago is an incoming third year resident at Ascension St. Vincent Hospital in Indianapolis, where she's completing her podiatric surgical residency training under Dr. Patrick DeHeer. In addition to her clinical training, she's involved in education and advocacy, mentorship, and professional leadership initiatives within podiatric medicine. In today's discussion, we'll address some common misconceptions, review prescribing pitfalls, and explore practical strategies for managing post-op pain while maintaining compliance with standards and regulations.

Dr. Santiago, thank you so much for being here and joining us again today.

Savannah Santiago, DPM: Oh, I'm so happy to be here and so excited to talk about such an important topic in podiatric medicine.

Jennifer Spector, DPM: It really is and we see it again and again and it's reinforced every year, every licensing cycle for most of us that are continuing our education in opioid risk mitigation. And the conversation around this has changed a lot over the past decade or so. What are some of the biggest misconceptions that you see that clinicians are still encountering?

Savannah Santiago, DPM: I would say most often, I've given this lecture a couple of times and most often people come up to me after and tell me that in the 1990s people were using pain as a vital sign. And so it was very, very important that part of the doctor's role was having to control that pain. And that was one of those initial spikes that we saw in opioid prescribing because it was required for us as surgeons, as physicians to be treating that patient's pain. And treating a patient's pain, surgery is painful. It's important. One of the biggest things that I think the biggest takeaway is multimodal approaches to treating pain. So getting a regional block when you can, making sure that the patient knows icing is an option, rotating in NSAIDs, elevation, doing a dressing change can make a huge change for a patient. So if you do the surgery on Friday and you're going to see them on Monday, doing that dressing change to help with edema management to help just put a clean dressing on is a huge change in the mindset for the patient on how they're interpreting pain.

Jennifer Spector, DPM: What do you feel are some of the most common prescribing pitfalls that are putting providers at risk? That could be risk for patient care issues, documentation issues, regulatory issues. It seems like there's a lot of potential missteps.

Savannah Santiago, DPM: There are a ton of potential missteps and opioids are something that are really closely looked at. The biggest thing is having the same prescribing method for every single patient. So treating a patient on a patient by patient basis. So you're going to have some patients who are neuropathic and don't require any pain medicine because they don't feel anything. And you'll have some patients who are on a pain contract and have a history of opioid use or have a history of opioid abuse and you have to treat those patients differently than you would treat that neuropathic patient that maybe doesn't need any pain medicine. And some patients maybe don't want a regional block because they've had one in the past and they didn't do well with it or some patients would do amazing with a regional block and using something like a regional block decreases the amount of opioids in that first 24-hour period, which is when opioid use is known and pain is known to be the highest.

So looking at every single patient on an individual basis and looking at every surgery on an individual basis, if you're prescribing the same amount of opioids for an ingrown toenail in clinic as you are for a bunion, as you are for an ankle fracture, those are all very different surgeries that will have very different pain modalities for different types of patients.

Jennifer Spector, DPM: And here's the key question. I know there's really not one answer to this, but I do think it's something worth consideration for all podiatrists. When we're planning our postoperative pain management, what strategies do you think can help us balance effective pain control with that responsible prescribing?

Savannah Santiago, DPM: So I do think that that then goes back to going to the patient on an individual basis and looking at the patient, knowing what you know about the patient, pre-op counseling with the patient. So I think that initial pre-op visit that you have with the patient tells you a ton. So asking the patient if they have been on opioids before, asking the patient if they've ever had a problem with opioids before, if they have a history of alcohol abuse, if they have a history of any other polysubstance abuse, asking the patient if there's going to be someone, an adult with them for 24 hours after surgery. They're going to be in a lot more pain after surgery if they're by themselves trying to hobble around, get dinner, turn on the TV, do whatever than if they have someone helping them. If they have an ability to offload, if you're going to have them non-weightbearing, how are you going to have them non-weightbearing?

Are they going to be on crutches on a knee scooter? Do they have the ability to do that? Do they have the physique to be doing that? They're going to be in a lot more pain if they haven't done any prehab and there's someone who can't handle crutches or can't handle a knee scooter. So I think part of it is just planning with the procedure itself, discussion with the patient. If that patient has a history of opioid use or opioid tolerance, working with pain management, knowing what that patient's pain contract is and the next steps moving forward, planning and telling the patient like, "Hey, your first 24 hours, we're going to be doing a block so you're not going to be feeling, but getting ahead of the pain, making sure that they know they should be elevating, they know they should be icing." And at the end of the day, this all sounds relatively easy and it sounds like something like, "Oh, well, we just need to talk to the patient," but we all know we talk to the patients and we tell them all of these things and they very often don't listen to us or they forget what we see.

So also having handouts that have all of this information that you can fill out and you can give to the patient so they know what to do postoperatively. Additionally, making sure that the family knows what's going on, they know there are different options for pain management and how you plan to mitigate that. Oftentimes there can be a lot of anxiety associated with postoperative pain as well. So just going about that in a stepwise fashion and planning for all different possibilities and documenting it. So if you know that the patient has a history of opioid use or has a history of opioid abuse and a pain contract documenting that you talk to the patient about X, Y, Z with really any time that you're prescribing opioids, it's always going to help protect yourself in your practice

Jennifer Spector, DPM: Absolutely. And a patient-focused approach I think will go so far for folks here. Thank you so much for being with us today, Dr. Santiago and for sharing your expertise with us.

Savannah Santiago, DPM: Of course. Thank you so much for having me. There's lots more to learn about opioids.

Jennifer Spector, DPM: Absolutely there is, and I'm sure your track at the APMA National will start to dive into some of these concepts since responsible pain management requires that thoughtful decision-making and careful documentation. Staying informed about those best practices can help clinicians provide that effective pain control while minimizing risk for both patients and themselves. Thank you to everyone listening to the Podiatry Today Podcast today. We hope you found the discussion informative and applicable to your practice. Be sure to subscribe and visit podiatry today or your favorite podcast platforms for additional clinical insights, expert commentary, and educational resources. We'll see you next time.