Editorial: The Opioid Epidemic and Orthopaedic Surgery—No Pain, Who Gains?

Leopold, Seth S.; Beadling, Lee

doi:10.1007/s11999-017-5454-y

Cited by 25 publications

(15 citation statements)

References 18 publications

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“…2 Also, unclear and conflicting recommendations from US regulatory bodies has led to confusion among orthopaedic surgeons regarding how to safely treat their patient's pain. 3 Finally, although many orthopaedic surgeries are now performed arthroscopically, recent data have shown that the pain of arthroscopic shoulder and knee ligament surgery is equal to or exceeds that of traditional arthroplasties and back surgeries. 4 Ketamine (C 13 H 16 ClNO) is a phencyclidine-class intravenous anaesthetic drug that antagonises the excitatory Nmethyl-D-aspartate (NMDA) receptor in the CNS.…”

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confidence: 99%

Low-dose ketamine in painful orthopaedic surgery: a systematic review and meta-analysis

Riddell

Trummel

Onakpoya

2019

British Journal of Anaesthesia

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Background: Ketamine is a phencyclidine intravenous anaesthetic that blocks N-methyl-D-aspartate receptors and HCN channels in the CNS. Lately it has gained acceptance in a low-dose form, with studies showing an analgesic benefit in orthopaedic surgery. Our goal was to critically appraise and synthesise current evidence regarding use of low-dose ketamine in major, painful orthopaedic surgeries. Methods: We conducted searches in Medline, Embase, Cochrane, and specialty journals for randomised controlled trials (RCTs) that compared low-dose ketamine to placebo. Primary outcomes included total opioid use, time to first opioid, and VAS pain scores. Meta-analyses were undertaken in RevMan software using a random effects model. We rated the quality of the evidence using the GRADE Working Group criteria. Results: We included 20 studies across four subgroups for meta-analysis. The overall quality of the evidence was moderate. Ketamine significantly decreased total opioid use and pain scores (VAS) at 24 and 48 h (Opioid: standardised mean difference [SMD] e0.82 [e1.24, e0.40], p¼0.0001, and e0.65 [e1.03,e0.27], p¼0.0008; VAS: SMD e0.53 [e0.91, e0.15], p¼0.006 and e0.60 [e1.05, e0.16], p¼0.008), and delayed the time to first opioid dose (SMD 0.64 [0.01, 1.27], p¼0.05). Results for nausea and hallucinations were equivocal, whereas results for chronic pain were inconclusive. The most prominent effects were seen in total joint operations. Conclusion: Low-dose ketamine is an effective adjuvant that decreases pain and opioid requirements in painful orthopaedic procedures, especially in the first 24 h after procedure. Future research should focus on arthroscopic procedures and the incidence of chronic pain.

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confidence: 99%

Low-dose ketamine in painful orthopaedic surgery: a systematic review and meta-analysis

Riddell

Trummel

Onakpoya

2019

British Journal of Anaesthesia

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“…Doing so would eliminate the vast negative effects of opioid use, including concerningly high misuse and abuse rates in prescribed users and a high frequency of adverse side effects [12]. Moreover, this is of particular importance to orthopedic researchers as the United States is currently in the middle of the world's worst opioid epidemic [13][14][15][16][17][18], with opioid addiction and overdose rates rising rapidly over the last quarter-century and orthopedic surgery being the single largest prescribing medical specialty [19,20]. Fortunately, the data presented in this systematic review indicates that several non-pharmacologic interventions may be viable to replace opioids as the primary perioperative analgesic for TKA and ACL reconstruction operations.…”

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confidence: 99%

“…Additionally, the United States is in the middle of the world's largest opioid epidemic [13][14][15][16][17][18], single-handedly consuming 80% of the world's opioid supply [20]. More than 4% of the countries' adult population currently misuses opioids [14], with 92% of these individuals misusing only physicianprescribed opioids and no other controlled substances [15], leading to an average of 130 Americans dying every day from opioid overdose [16].…”

Section: Introductionmentioning

confidence: 99%

Reduction in opioid use with perioperative non-pharmacologic analgesia in total knee arthroplasty and ACL reconstruction: a systematic review

Juncker

Mirza

Gagnier

2021

SICOT-J

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Introduction: The world’s opioid epidemic has gotten increasingly severe over the last several decades and projects to continue worsening. Orthopedic surgery is the largest contributor to this epidemic, accounting for 8.8% of postoperative opioid dependence cases. Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction are commonly performed orthopedic operations heavily reliant on opioids as the primary analgesic in the peri- and immediate postoperative period. These downfalls highlight the pressing need for an alternate, non-pharmacologic analgesic to reduce postoperative opioid use in orthopedic patients. The presented systematic review aimed to analyze and compare the most promising non-pharmacologic analgesic interventions in the available literature to guide future research in such a novel field. Methods: A systematic search of PubMed, MEDLINE, Embase, Cochrane, and Web of Science was performed for studies published before July 2020 based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, and the obtained manuscripts were evaluated for inclusion or exclusion against strict, pre-determined criteria. Risk-of-bias and GRADE (grades of recommendation, assessment, development, and evaluation) assessments were then performed on all included studies. Results: Six studies were deemed fit for inclusion, investigating three non-pharmacologic analgesics: percutaneous peripheral nerve stimulation, cryoneurolysis, and auricular acupressure. All three successfully reduced postoperative opioid use while simultaneously maintaining the safety and efficacy of the procedure. Discussion: The results indicate that all three presented non-pharmacologic analgesic interventions are viable and warrant future research. That said, because of its slight advantages in postoperative pain control and operational outcomes, cryoneurolysis seems to be the most promising. Further research and eventual clinical implementation of these analgesics is not only warranted but should be a priority because of their vast potential to reduce orthopedics surgeries’ contribution to the opioid epidemic.

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“…16 The opioid crisis has received significant press in the past few years, and the Department of Health and Human Services has labeled it a public health emergency. 4,11,14 Orthopaedic surgeons have one of the highest opioid prescribing rates of any health care profession. 23…”

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confidence: 99%

Opioid Prescribing Trends and Geographic Variation After Anterior Cruciate Ligament Reconstruction

Marrache

Raad

Mikula

et al. 2020

Sports Health: A Multidisciplinary Approach

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Introduction: Opioid prescribing patterns play an important role in the opioid epidemic in the United States. The purpose of this study is to examine the trends and geographic variation in opioid prescribing patterns after anterior cruciate ligament (ACL) reconstruction. Hypothesis: Regional differences in opioid prescribing patterns after ACL reconstruction are present. Study Design: Descriptive epidemiology study. Level of Evidence: Level 4. Methods: The Truven Health MarketScan Commercial Claims database was used to analyze all patients with perioperative private insurance coverage who underwent ACL reconstruction from January 1, 2010, to November 31, 2017. Total number and morphine milligram equivalents per day (MMED) of opioid prescriptions were examined, and regional and statewide variation was assessed. Results: A total of 90,068 ACL reconstruction patients who underwent surgery between 2010 and 2017 were included in the study. Overall, 67% received an opioid prescription within 30 days of surgery and 17% received an opioid prescription ≥90 MMED. The West (20%) had the highest proportion of patients with an opioid prescription ≥90 MMED and the Northeast had the lowest (12%), P < 0.001. The number of opioid prescriptions as well as proportion of opioid prescriptions ≥90 MMED varied significantly by state, P < 0.001. There was a significant increase in number of opioid prescriptions from 2010 to 2017 (62% in 2010 and 83% in 2017; P < 0.001). A significant change in the proportion of patients being prescribed ≥90 MMED was also present ( P = 0.04; 15% in 2010, 17% in 2011, 17% 2012, 17% in 2013, 15% in 2014, 20% in 2015, 18% in 2016, and 15% in 2017). Conclusion: This study shows a trend of increasing opioid prescriptions and geographic variations in the amount and MMED of opioid prescriptions for patients undergoing ACL reconstruction. These data highlight several areas of improvement that state officials and national entities can use to help curb the opioid epidemic and underscore the importance of national guidelines for opioid prescribing. Clinical Relevance: Knowledge of prescribing patterns after specific procedures may help provide more direct insight and guidance to surgeons and patients regarding postoperative pain management.

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Editorial: The Opioid Epidemic and Orthopaedic Surgery—No Pain, Who Gains?

Cited by 25 publications

References 18 publications

Low-dose ketamine in painful orthopaedic surgery: a systematic review and meta-analysis

Low-dose ketamine in painful orthopaedic surgery: a systematic review and meta-analysis

Reduction in opioid use with perioperative non-pharmacologic analgesia in total knee arthroplasty and ACL reconstruction: a systematic review

Opioid Prescribing Trends and Geographic Variation After Anterior Cruciate Ligament Reconstruction

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