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Editorial Commentary: Opioid Sparing Through Patient Education Programs Is the Future for Sports Medicine and Arthroscopic Surgery to Optimize Outcome

      Abstract

      Opioid research in sports medicine and arthroscopic surgery has exploded in the last few years. The literature definitively shows that preoperative opioid usage—in so-called opioid exposed, tolerant, and familiar patients—increases postoperative usage, readmission rates, and medical complications, yielding poorer outcome. Strategies to combat the deleterious effects of preoperative opioid use should be used to include ownership and acknowledgment of the problem, adherence to opioid prescribing protocols, and use of a multimodal anesthesia program that can mitigate the adverse effects by limiting abuse and preventing potential poor outcome. Adding patient education programs to change patient modifiable risk factors shows promise while simultaneously optimizing appropriate patient expectations that are linked to increased outcome. Thus, opioid mitigation, sparing, or altogether avoidance through improved education programs and opioid prescribing protocols will likely be the future of sports medicine and arthroscopic surgery to optimize patient outcome.
      As a result of a justified response to the opioid crisis,
      • Rossi M.J.
      • Brand J.C.
      • Lubowitz J.H.
      Opioids after arthroscopy: We're only halfway through the crisis.
      opioid research in sports medicine and arthroscopic surgery has exploded in the last few years.
      • Alaia M.J.
      Editorial commentary: Uncle Sam wants YOU! (to stop the opioid crisis).
      • Andelman S.M.
      • Bu D.
      • Debellis N.
      • et al.
      Preoperative patient education may decrease postoperative opioid use after meniscectomy.
      • Andelman S.M.
      • Debellis N.
      • Bu D.
      • et al.
      Preoperative education significantly decreases postoperative opioid use after arthroscopic meniscectomy.

      Aneizi A, Sajak PMJ, Alqazzaz A, et al. Impact of preoperative opioid use on 2-year patient-reported outcomes in knee surgery patients [published online September 8, 2020]. J Knee Surg. doi:10.1055/s-0040-1716358.

      • Baron J.
      • Shamrock A.
      • Gulbrandsen T.
      • et al.
      Incidence and risk factors for prolonged opioid use after arthroscopic meniscal surgery: An analysis of 107,717 cases.
      • Beck E.
      • Nwachukwu B.
      • Drager J.
      • Jan K.
      • Nho S.
      • Rasio J.
      Prolonged postoperative opioid use after arthroscopic femoroacetabular impingement syndrome surgery: Predictors and outcomes at minimum two year follow-up.
      • Beck E.C.
      • Nwachukwu B.U.
      • Jan K.
      • et al.
      The effect of postoperative opioid prescription refills on achieving meaningful clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome.
      • Campbell K.A.
      • Baron S.L.
      • Bloom D.A.
      • Klein D.
      • Luthringer T.A.
      • Jazrawi L.M.
      Opioid education for arthroscopic shoulder surgery had no effect on consumption: A RCT.
      • 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.
      • Cronin K.J.
      • Mair S.D.
      • Hawk G.S.
      • Thompson K.L.
      • Hettrich C.M.
      • Jacobs C.A.
      Increased health care costs and opioid use in patients with anxiety and depression undergoing rotator cuff repair.
      • Cunningham D.J.
      • Mather R.C.
      • Olson S.A.
      • Lewis B.D.
      The association of prescriber awareness of opioid consumption trends with postoperative opioid prescription volume in hip arthroscopy: Prescriber awareness of opioid consumption.
      • Curran S.
      Additional factors in evaluating opioid use following arthroscopic knee surgery [published online March 17, 2020].
      • Daniels S.D.
      • Garvey K.D.
      • Collins J.E.
      • Matzkin E.G.
      Patient satisfaction with nonopioid pain management following arthroscopic partial meniscectomy and/or chondroplasty.
      • Farley K.X.
      • Wilson J.M.
      • Spencer C.C.
      • et al.
      Preoperative opioid use is a risk factor for revision surgery, complications, and increased resource utilization after arthroscopic rotator cuff repair.
      • Forlenza E.M.
      • Lavoie-Gagne O.
      • Lu Y.
      • et al.
      Preoperative opioid use predicts prolonged postoperative opioid use and inferior patient outcomes following anterior cruciate ligament reconstruction.
      • Fort J.B.S.A.
      • Rhon D.I.
      • San Antonio J.B.
      Comorbid insomnia and sleep apnea are associated with greater downstream health care utilization and chronic opioid use after arthroscopic hip surgery.

      Gazendam A, Ekhtiari S, Horner NS, Nucci N, Dookie J, Ayeni OR. Perioperative nonopioid analgesia reduces postoperative opioid consumption in knee arthroscopy: A systematic review and meta-analysis [published online September 5, 2020]. Knee Surg Sport Traumatol Arthrosc. doi:10.1007/s00167-020-06256-2.

      Glogovac G, Kennedy M, Parman MD, Bowers KA, Colosimo AJ, Grawe BM. Opioid requirement following arthroscopic knee surgery: Are there predictive factors associated with long-term use [published online November 28, 2019]? J Knee Surg. doi:10.1055/s-0039-3400754.

      • Hajewski C.J.
      • Westermann R.W.
      • Holte A.
      • Shamrock A.
      • Bollier M.
      • Wolf B.R.
      Impact of a standardized multimodal analgesia protocol on opioid prescriptions after common arthroscopic procedures.
      • Hartwell M.J.
      • Selley R.S.
      • Terry M.A.
      • Tjong V.K.
      Can we eliminate opioid medications for postoperative pain control? A prospective, surgeon-blinded, randomized controlled trial in knee arthroscopic surgery.
      • Jacobs C.A.
      • Hawk G.S.
      • Jochimsen K.N.
      • et al.
      Depression and anxiety are associated with increased health care costs and opioid use for patients with femoroacetabular impingement undergoing hip arthroscopy: Analysis of a claims database.
      • Jildeh T.R.
      • Taylor K.A.
      • Tramer J.S.
      • et al.
      Risk factors for postoperative opioid use in arthroscopic shoulder labral surgery.
      • Jildeh T.R.
      • Taylor K.A.
      • Tramer J.S.
      • Khalil L.S.
      • Hasan L.
      • Okoroha K.R.
      • Moutzouros V.
      Risk factors for postoperative opioid use in arthroscopic shoulder labral surgery.
      • Jildeh T.R.
      Editorial commentary: Postoperative analgesia after arthroscopy: A step toward the personalization of pain control.
      • Kamdar P.M.
      • Liddy N.
      • Antonacci C.
      • et al.
      Opioid consumption after knee arthroscopy.
      • Kamdar P.M.
      • Mandava N.K.
      • Narula A.
      • et al.
      Opioid use after knee arthroscopy.
      • Khazi Z.M.
      • Baron J.
      • Shamrock A.
      • et al.
      Preoperative opioid usage, male sex, and preexisting knee osteoarthritis impacts opioid refills after isolated arthroscopic meniscectomy: A population-based study.
      • Khazi Z.M.
      • Lu Y.
      • Shamrock A.G.
      • Duchman K.R.
      • Westermann R.W.
      • Wolf B.R.
      Opioid use following shoulder stabilization surgery: risk factors for prolonged use.
      • Khazi Z.M.
      • Shamrock A.G.
      • Hajewski C.
      • et al.
      Preoperative opioid use is associated with inferior outcomes after patellofemoral stabilization surgery.
      • Klein D.
      • Campbell K.
      • Jazrawi L.
      • Bloom D.
      • Baron S.
      Preoperative opioid education has no effect on opioid use in patients undergoing arthroscopic rotator cuff repair: A prospective, randomized clinical trial.
      • Kunze K.N.
      • Polce E.M.
      • Lilly D.T.
      • et al.
      Adjunct analgesia reduces pain and opioid consumption after hip arthroscopy: A systematic review of randomized controlled trials.
      • Li N.Y.
      • DeFroda S.F.
      • Durand W.
      • Reid D.B.C.
      • Owens B.D.
      • Daniels A.H.
      Risk of revision shoulder surgery, complications, and prolonged opioid use in patients undergoing shoulder arthroscopy who have previously undergone anterior cervical discectomy and fusion.
      • Lovecchio F.
      • Premkumar A.
      • Uppstrom T.
      • et al.
      Opioid consumption after arthroscopic meniscal procedures and anterior cruciate ligament reconstruction.
      • Lu Y.
      • Beletsky A.
      • Cohn M.R.
      • et al.
      Perioperative opioid use predicts postoperative opioid use and inferior outcomes after shoulder arthroscopy.

      Lu Y, Forlenza E, Wilbur RR, et al. Machine-learning model successfully predicts patients at risk for prolonged postoperative opioid use following elective knee arthroscopy [published online January 9, 2021]. Knee Surg Sport Traumatol Arthrosc. doi:10.1007/s00167-020-06421-7.

      • Mandava N.
      • Delos D.
      • Vadasdi K.
      • et al.
      An evidence driven opioid prescribing guideline following knee arthroscopy and anterior cruciate ligament reconstruction.
      • McDowell C.M.
      • Bradian A.K.
      • Cheesman Q.T.
      • et al.
      The effect of state legislation on opioid prescriptions following arthroscopic rotator cuff repair.
      • Rojas E.O.
      • Khazi Z.M.
      • Gulbrandsen T.R.
      • et al.
      Preoperative opioid prescription filling is a risk factor for prolonged opioid use after elbow arthroscopy.

      Ryan R, Christopher K, Aditya Y, et al. Preparative opioid use is associated with persistent use, readmission and postoperative complications after arthroscopic knee surgery [published online December 16, 2020]. Arthroscopy. doi:10.1016/j.arthro.2020.12.187.

      Selley RS, Hartwell MJ, Alvandi BA, Terry MA, Tjong VK. Risk factors for increased consumption of narcotics after hip arthroscopy: A prospective, randomized control trial [published online November 26, 2020]. J Am Acad Orthop Surg. doi:10.5435/JAAOS-D-20-00122.

      • Shah K.N.
      • Ruddell J.H.
      • Reid D.B.C.
      • et al.
      Opioid-limiting regulation: Effect on patients undergoing knee and shoulder arthroscopy.
      • Sheth U.
      • Mehta M.
      • Huyke F.
      • Terry M.A.
      • Tjong V.K.
      Opioid use after common sports medicine procedures: A systematic review.
      • Stepan J.G.
      • Lovecchio F.C.
      • Premkumar A.
      • et al.
      Development of an institutional opioid prescriber education program and opioid-prescribing guidelines: Impact on prescribing practices.
      • Syed U.A.M.
      • Aleem A.W.
      • 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.
      • Thompson K.A.
      • Klein D.S.
      • Gonzalez-Lomas G.
      • et al.
      Opioid use is reduced in patients treated with NSAIDs after arthroscopic shoulder instability repair: A randomized study.
      • Trasolini N.A.
      • Bolia I.K.
      • Kang H.P.
      • et al.
      National trends in use of regional anesthesia and postoperative patterns of opioid prescription filling in shoulder arthroscopy: A procedure-specific analysis in patients with or without recent opioid exposure.
      • Weekes D.G.
      • Feldman J.A.
      • Campbell R.E.
      • DeFrance M.
      • Tjoumakaris F.P.
      • Austin L.
      The incidence of chronic opioid use following arthroscopic rotator cuff repair and patient opioid education.
      • Zusmanovich M.
      • Thompson K.
      • Campbell A.
      • Youm T.
      Outcomes of preoperative opioid usage in hip arthroscopy: A comparison with opioid-naïve patients.
      Large database study designs
      • Dhawan A.
      • Brand J.C.
      • Rossi M.J.
      • Lubowitz J.H.
      Big data: Progress or a big headache?.
      harness the power of high numbers to uncover associations of patient risk factors, both modifiable and nonmodifiable, to complications and outcomes. Authors from Hershey, Pennsylvania, Ridenour, Kowalski, Yadavalli, Ba, Liu, Leslis, Bible, Aynardi, Garner, and Associate Editor Dhawan, keenly use this very technique to analyze over 1 million patients in their study, “Preparative Opioid Use Is Associated With Persistent Use, Readmission and Postoperative Complications After Arthroscopic Knee Surgery.”
      • Ridenour
      • Kowalski Yadavalli
      • et al.
      Preparative opioid use is associated with persistent use, readmission and postoperative complications after arthroscopic knee surgery.
      The authors show that nearly 12% of the patients are opioid exposed prior to knee arthroscopic surgery. The literature also conveniently refers to these exposed patients as opioid tolerant
      • Alaia M.J.
      Editorial commentary: Uncle Sam wants YOU! (to stop the opioid crisis).
      (if you prefer a softer, less negative, term) or even opioid familiar (if you rather prefer something more positive).
      • Rossi M.J.
      • Brand J.C.
      • Lubowitz J.H.
      Opioids after arthroscopy: We're only halfway through the crisis.
      Regardless, these opioid exposed, tolerant, and familiar patients harbor increased risk of prolonged opioid usage at all times postoperative with an odds ratio as high as 15. In addition, mental health disease, smoking, chronic pain, diabetes, chronic regional pain syndrome (but not obesity), and use of pregabalin, gabapentin, benzodiazepine, or antidepressant medications are also increased risk factors of increased opioid usage. Furthermore, opioid familiar patients have higher readmission rates at 90 days with higher medical complications such as deep venous thrombosis, pulmonary embolism, surgical site infection, urinary tract infection, pain, and postoperative bleeding.
      To summarize, preoperative opioid usage increases postoperative usage, readmission rates, and medical complications—all of which have been shown consistently in the literature. Interestingly, despite nearly 12% of the patients being opioid familiar, only 4% maintained opioid use at 6 to 12 months and only 2% at >12 months. Perhaps this is telling us that there is hope despite the poorer prognosis for these patients, and some are, in fact, weaning.
      We have endorsed strategies to combat the deleterious effects of preoperative opioid use.
      • Rossi M.J.
      • Brand J.C.
      • Lubowitz J.H.
      Opioids after arthroscopy: We're only halfway through the crisis.
      ,
      • Hrnack S.A.
      Editorial commentary: Houston, we have a problem! A really big opioid problem!.
      These necessary steps include ownership and acknowledgment of the problem, adherence to opioid prescribing protocols, and use of a multimodal anesthesia program. Certainly, employing these strategies can mitigate the adverse effects by limiting abuse and preventing potential poor outcome. We as surgeons can run into ethical dilemmas if we select out patients who truly have surgical problems that can be potentially improved with surgery by denying surgical care simply because they are taking—or more likely have been given—opioids. If given the choice, it would be more preferable to educate or change patients’ risk factors rather than avoid care altogether.
      Recently, there have been studies on patient education programs to change the patient modifiable risk factors. In the shoulder literature, there have been varying reports of success both with beneficial impact
      • 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.
      ,
      • Syed U.A.M.
      • Aleem A.W.
      • 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.
      or no impact.
      • Campbell K.A.
      • Baron S.L.
      • Bloom D.A.
      • Klein D.
      • Luthringer T.A.
      • Jazrawi L.M.
      Opioid education for arthroscopic shoulder surgery had no effect on consumption: A RCT.
      ,
      • Klein D.
      • Campbell K.
      • Jazrawi L.
      • Bloom D.
      • Baron S.
      Preoperative opioid education has no effect on opioid use in patients undergoing arthroscopic rotator cuff repair: A prospective, randomized clinical trial.
      On the other hand, the tested knee education programs have shown more generally positive success, which is reassuring.
      • Andelman S.M.
      • Bu D.
      • Debellis N.
      • et al.
      Preoperative patient education may decrease postoperative opioid use after meniscectomy.
      ,
      • Andelman S.M.
      • Debellis N.
      • Bu D.
      • et al.
      Preoperative education significantly decreases postoperative opioid use after arthroscopic meniscectomy.
      The verdict on these specific patient education programs is not out but promising. Being early in this research, it is certainly difficult to imagine that the type of joint (knee, shoulder, ankle, elbow, etc) would impact the outcome of such patient education programs.
      It makes more sense that outcome can be optimized through appropriate patient expectations,
      • Rossi M.J.
      • Brand J.C.
      • Provencher M.T.
      • Lubowitz J.H.
      The expectation game: Patient comprehension is a determinant of outcome.
      which can be guided during preoperative discussion. It is before surgery that optimal fitness for surgery can be addressed with education to change the modifiable patient risk factors to improve outcome.
      Thus, opioid mitigation, sparing, or altogether avoidance through improved education programs and opioid prescribing protocols will likely be the future of sports medicine and arthroscopic surgery to optimize patient outcome.

      Supplementary Data

      References

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        Opioids after arthroscopy: We're only halfway through the crisis.
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        Editorial commentary: Uncle Sam wants YOU! (to stop the opioid crisis).
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        Preoperative education significantly decreases postoperative opioid use after arthroscopic meniscectomy.
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        Impact of a standardized multimodal analgesia protocol on opioid prescriptions after common arthroscopic procedures.
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        • Hartwell M.J.
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        Risk factors for postoperative opioid use in arthroscopic shoulder labral surgery.
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        Editorial commentary: Postoperative analgesia after arthroscopy: A step toward the personalization of pain control.
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        Opioid consumption after arthroscopic meniscal procedures and anterior cruciate ligament reconstruction.
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        Perioperative opioid use predicts postoperative opioid use and inferior outcomes after shoulder arthroscopy.
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        • Delos D.
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        • et al.
        An evidence driven opioid prescribing guideline following knee arthroscopy and anterior cruciate ligament reconstruction.
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        • McDowell C.M.
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