Opioid stewardship: Simple pain-management strategies decrease the risk of opioid abuse after orthopaedic surgery

Substance use disorder, particularly related to opioid abuse, is an aspect of mental health that orthopaedic surgeons must be aware of anytime they consider pain-management options for their patients’ conditions, injuries, or surgeries. Although opioid dependency is a multifactorial problem, orthopaedic surgeons have broadly embraced the mantle of opioid stewardship, recognizing that opioid dependency and abuse are often initiated after a legitimate opioid prescription following an injury or surgery. Despite news from the Centers for Disease Control and Prevention in 2024 that there was a decline in annual opioid-related deaths, it continues to be the leading cause of death among young adult Americans.

Risk of opioid dependency is higher in patients with a history of substance use or various mental health diagnoses — conditions that orthopaedic surgeons are often unaware of. Fortunately, there has been extensive research in opioid-sparing pain management in recent years, lending to the development of several straightforward and easy-to-employ evidence-based strategies that can be incorporated by all orthopaedic surgeons, regardless of their specialty and practice paradigm. These strategies include avoiding inadvertent overprescribing, leveraging multimodal pain-management strategies, and employing preoperative opioid counseling.

As the opioid crisis began to take root in America, studies suggested a high rate of opioid overprescribing by orthopaedic surgeons. This tendency was driven by a desire to ensure that patients had enough pain medication, minimize patient phone calls, avoid patient complaints, and overcompensate for the requirement of in-person paper prescription refills in many states. Another factor that may have contributed to overprescribing was uncertainty about how much pain patients may experience after surgery.

Plenty of evidence now exists to help surgeons identify the appropriate amount of opioids most patients need after various surgeries. Aside from following the results in published research, surgeons can simply ask their patients what they typically consume to get a sense of postoperative opioid needs for their patients relative to their specialty, surgical technique, and practice demographics. The fundamental spirit of avoiding overprescribing is to minimize prescribing opioids that may be taken unnecessarily or diverted to family members, friends, or the surrounding community.

Multimodal pain management involves influencing the pain pathway at multiple points. Orthopaedic surgeons can influence the pain pathway by using local anesthetics at the surgical site; ice, cryotherapy, or NSAIDs to decrease inflammation; gabapentinoids to slow pain conduction; and acetaminophen to decrease the pain experience. All this can be done safely along the pain pathway to affect pain perception in the brain, before an opioid is even needed. Research is replete with studies evaluating multimodal pain strategies across all subspecialties, broadly demonstrating efficacy in effectively managing patients’ pain while decreasing the reliance on opioids.

A recent study by Turk et al demonstrated that multimodal strategies can be employed to eliminate the need for opioids across various orthopaedic surgical subspecialties. However, for multimodal strategies to work, the first-line medications used, including NSAIDs and acetaminophen, must be taken on a scheduled basis, not as needed. Prescribed opioids can then be taken as needed for breakthrough pain.

Research has also shown that preoperative opioid counseling can be highly effective in educating patients on safe pain management after surgery and decreasing the reliance on opioids postoperatively. Several studies have looked at different counseling strategies, including reviewing printed literature and providing videos for patients to watch preoperatively, and both have been shown to be effective. Deliberate preoperative counseling prepares patients to better understand their pain, the risks and benefits of their medications, and nonpharmacological and pharmacological pain strategies. These strategies empower the patient to be proactive and prepare them to manage their pain in a strategic and safe manner postoperatively.

Mental health disorders, particularly substance abuse including opioid dependency, are complex but important considerations for orthopaedic surgeons when managing their patients’ pain. Fortunately, easy-to-implement evidence-based strategies can be readily employed to help reduce the risk of opioid dependency, including avoiding inadvertent overprescribing, leveraging multimodal pain-management strategies, and employing preoperative opioid counseling. Fundamental to this process is maintaining overall vigilance of the risks of opioid dependency and substance abuse in orthopaedic patients while embracing opioid stewardship.

Asif Ilyas, MD, MBA, FAAOS, is a partner at Rothman Orthopaedics, professor and vice chairman of orthopaedic surgery at the Drexel University College of Medicine, and president of the Rothman Opioid Foundation.

References

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