JENNA ADALBERT, BS
SOMMER HAMMOUD, MD
Orthopaedic sports medicine subspecialists perform a wide variety of anatomic procedures requiring post-operative opioids for pain management.
Pre-operative patient education and assessment of specific risk factors can reduce the need and length of post-operative opioid use.
Multimodal pain management regimens during the peri-operative period can significantly reduce post-operative levels of opioid consumption.
Procedure-specific prescribing guidelines and patient education on proper opioid disposal can minimize opioid consumption and prevent the dissemination of excess opioids into the community.
One of several orthopaedic subspecialties, sports medicine is a particularly diverse orthopaedic concentration that spans a realm of anatomic procedures. Sports medicine orthopaedists surgically manage musculoskeletal injuries that result from athletics (or exercise) as well as injured individuals trying to increase physical mobility or regain function.1 Commonly injured areas requiring sports medicine expertise include the knee (i.e. anterior cruciate ligament tears), hip (i.e. femoroacetabular impingement), ankle (i.e. lateral ankle ligament sprain), spine (i.e. disc herniation), and shoulder (i.e. rotator cuff tears).2 Given the severity of the United States’ opioid epidemic and the contribution of orthopaedic surgeons as the third-highest specialty prescribers,3 it is important to further explore opioid-minimizing pain management strategies in sports medicine due to the wide variety of procedures performed by this subspecialty.2 This Research Brief will outline the risk stratification tools and evidence-based recommendations currently purposed to mitigate the sports medicine contribution to the opioid epidemic from a pre-, peri-, and post-operative perspective.
Pre-Operative Opioid Interventions
Increasingly, emphasis has been placed on the orthopaedic provider role in pre-operative patient opioid education on correct use, adverse effects, and the potential for misuse.4 Syed et al. performed a randomized controlled trial with pre-operative patients undergoing arthroscopic rotator cuff repair (RCR), consisting of a brief narrated video accompanied by an educational handout detailing the risks of potential opioid misuse. At the three-month follow-up, the intervention group subsequently consumed 42% fewer opioids and was 2.2 times more likely to discontinue opioid use in comparison to the control group.5 At a follow-up analysis two years later, Cheesman et al. assessed this cohort for long-term opioid dependence and found that the intervention group had a lower rate of dependence than the control group (11.4% vs. 25.7%), emphasizing a key potential area for opioid dependence reduction in the arthroscopic patient population.6
Additionally, a thorough pre-operative assessment of patient history and risk factors is an important predictor of poorly managed postoperative pain and potential opioid dependence following arthroscopic sports medicine procedures.7–10 In particular, Gil et al. assessed risk factors for prolonged opioid use in patients undergoing arthroscopic shoulder procedures and found that perioperative doses of ≥743 oral morphine equivalents (≥149 tablets of 5-mg hydrocodone), an opioid prescription filled within 30 days of surgery, female gender, and a history of suicide or self-harm disorders, alcohol dependence/abuse, mood/anxiety disorders, or a pain diagnosis were significant predictors.9 Granadillo et al. conducted a similar review of hip arthroscopy patients, identifying previous prescriptions (opioids, muscle relaxants or anxiolytics), substance use/abuse, morbid obesity, and chronic back pain as important factors that extended opioid necessity.10 Application of these results can stratify patients into risk groups based on history through pre-operative identification of patients requiring higher levels of surveillance for post-operative opioid misuse.9,10
Peri-Operative Opioid Interventions
During the peri-operative period of sports medicine procedures, incorporating multimodal analgesics and anesthetics has the important role of reducing the amount of opioid medication required for adequate pain management.11,12 Elkassabany et al. assessed the quality of recovery in patients undergoing outpatient shoulder arthroscopy procedures that received a multimodal perioperative pain management regimen consisting of pre-operative (acetaminophen, gabapentin, interscalene brachial plexus block), intra-operative (ketorolac, dexamethasone, ondansetron), and post-operative (acetaminophen, gabapentin, ketorolac, oxycodone, and ondansetron) components. Compared to control patients managed with standard post-operative oxycodone/acetaminophen as needed, patients receiving the multimodal intervention reported a superior quality of pain management and significantly reduced levels of post-operative opioid consumption.12 Similarly, Hajewski et al. reviewed the implementation of a multimodal analgesic regimen (gabapentin, acetaminophen and NSAIDs in addition to opioids) for patients undergoing common arthroscopy procedures (menisectomy, rotator cuff repair, or anterior cruciate ligament reconstruction) and observed that this protocol significantly reduced post-operative opioid consumption and refills compared to traditional opioid prescribing. In addition to reducing reliance on opioid medications for pain management, these types of multimodal approaches improve patient pain relief and importantly limit adverse side effects that may manifest from a high dose of one particular drug.4
Post-Operative Opioid Interventions
Along with incorporating multimodal analgesia into prescribing, a significant post-operative focus has been placed on creating procedure-specific opioid guidelines for common sports medicine orthopaedic procedures.13–16 Utilizing a 3-step modified Delphi method for the development of opioid prescribing guidelines, Overton et al. recommended a maximum of 10 to 20 tablets of oxycodone 5mg (75, 150, and 150 MMEs) for arthroscopic partial meniscectomy, anterior cruciate ligament repair, and rotator cuff repair.13 And through both prospective and retrospective review, a multitude of studies have analyzed patient consumption following specific procedures to create opioid recommendations to guide orthopaedic provider prescribing discretion.14–17 While specific patient needs may exceed recommended opioid guidelines, excessive distribution can be prevented through provision of several smaller prescriptions until adequate pain management is achieved.4 Finally, of paramount post-operative importance is patient counseling on appropriate storage of opioid medications and proper disposal of residual prescriptions to prevent unintentional diversion and misuse.18
1. The Basics for Understanding Orthopedic Sports Medicine: Alpha Orthopedics & Sports Medicine: Orthopedic Surgeons. https://www.alphaortho.net/blog/the-basics-for-understanding-orthopedic-sports-medicine. Accessed September 14, 2020.
2. Vasta S, Papalia R, Albo E, Maffulli N, Denaro V. Top orthopedic sports medicine procedures. J Orthop Surg Res. 2018;13(1):190. doi:10.1186/s13018-018-0889-8
3. Guy GP, Zhang K. Opioid prescribing by specialty and volume in the U.S. Am J Prev Med. 2018;55(5):e153-e155. doi:10.1016/j.amepre.2018.06.008
4. Sheth U, Mehta M, Huyke F, Terry MA, Tjong VK. Opioid use after common sports medicine procedures: A systematic review. Sports Health. 2020;12(3):225-233. doi:10.1177/1941738120913293
5. Syed UAM, Aleem AW, Wowkanech C, et al. Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial. J Shoulder Elbow Surg. 2018;27(6):962-967. doi:10.1016/j.jse.2018.02.039
6. Cheesman Q, DeFrance M, Stenson J, et al. The effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial-2-year follow-up. J Shoulder Elbow Surg. 2020;29(9):1743-1750. doi:10.1016/j.jse.2020.04.036
7. Khazi ZM, Shamrock AG, Hajewski C, et al. Preoperative opioid use is associated with inferior outcomes after patellofemoral stabilization surgery. Knee Surg Sports Traumatol Arthrosc. 2020;28(2):599-605. doi:10.1007/s00167-019-05738-2
8. Smith SR, Bido J, Collins JE, Yang H, Katz JN, Losina E. Impact of preoperative opioid use on total knee arthroplasty outcomes. J Bone Joint Surg Am. 2017;99(10):803-808. doi:10.2106/JBJS.16.01200
9. Gil JA, Gunaseelan V, DeFroda SF, Brummett CM, Bedi A, Waljee JF. Risk of Prolonged Opioid Use Among Opioid-Naïve Patients After Common Shoulder Arthroscopy Procedures. Am J Sports Med. 2019;47(5):1043-1050. doi:10.1177/0363546518819780
10. Anciano Granadillo V, Cancienne JM, Gwathmey FW, Werner BC. Perioperative opioid analgesics and hip arthroscopy: trends, risk factors for prolonged use, and complications. Arthroscopy. 2018;34(8):2359-2367. doi:10.1016/j.arthro.2018.03.016
11. Hajewski CJ, Westermann RW, Holte A, Shamrock A, Bollier M, Wolf BR. Impact of a standardized multimodal analgesia protocol on opioid prescriptions after common arthroscopic procedures. Orthop J Sports Med. 2019;7(9):2325967119870753. doi:10.1177/2325967119870753
12. Elkassabany NM, Wang A, Ochroch J, Mattera M, Liu J, Kuntz A. Improved Quality of Recovery from Ambulatory Shoulder Surgery After Implementation of a Multimodal Perioperative Pain Management Protocol. Pain Med. 2019;20(5):1012-1019. doi:10.1093/pm/pny152
13. Overton HN, Hanna MN, Bruhn WE, et al. Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus. J Am Coll Surg. 2018;227(4):411-418. doi:10.1016/j.jamcollsurg.2018.07.659
14. Saini S, McDonald EL, Shakked R, et al. Prospective evaluation of utilization patterns and prescribing guidelines of opioid consumption following orthopedic foot and ankle surgery. Foot Ankle Int. 2018;39(11):1257-1265. doi:10.1177/1071100718790243
15. Mandava N, Delos D, Vadasdi K, et al. An Evidence Driven Opioid Prescribing Guideline following Knee Arthroscopy and Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med. 2020;8(7_suppl6):2325967120S0039. doi:10.1177/2325967120S00393
16. Anthony CA, Westermann RW, Bedard N, et al. Opioid demand before and after anterior cruciate ligament reconstruction. Am J Sports Med. 2017;45(13):3098-3103. doi:10.1177/0363546517719226
17. Kim N, Matzon JL, Abboudi J, et al. A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines. J Bone Joint Surg Am. 2016;98(20):e89. doi:10.2106/JBJS.15.00614
18. Nahhas CR, Hannon CP, Yang J, Gerlinger TL, Nam D, Della Valle CJ. Education Increases Disposal of Unused Opioids After Total Joint Arthroplasty: A Cluster-Randomized Controlled Trial. J Bone Joint Surg Am. 2020;102(11):953-960. doi:10.2106/JBJS.19.01166