Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Abstract

Background Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area. Methods This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines. Results A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence. Conclusions This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Prevalence and Predictors of Long-term Opioid Use After Pelvic Fractures

“…19 On a system level, interventions in hospital guidelines and protocols for opioid prescription have been associated with decreased opioid use in the long run. 20 Our study was notable in that we evaluated opioid use specifically in patients with pelvic fractures which has not previously been investigated in depth. There were several limitations.…”

Stratégies pour éviter l’utilisation à long terme des opioïdes après un traumatisme : enquête sur les pratiques canadiennes

“…Many of the strategies perceived to be frequently used and most effective are those associated with significant decreases in opioid long-term use following trauma or recommended in several practice guidelines, as shown in a recent scoping review. 32 These include multimodal analgesia, guidelines and protocols, training for clinicians, educational strategies for patients with or without support for opioid tapering, and prescription monitoring systems. Guidelines and education are strategies fostering knowledge, decision processes, awareness of consequences and reinforcement, which are the underpinnings of the capacity and motivation to adopt the desired behavior, 67 including those aimed at alleviating pain and reducing opioid use.…”

“…Two preventive strategies rated as likely to be highly effective following traumatic injury by our survey respondents—i.e., physical stimulation and establishing communication mechanisms between professionals to optimize the follow-up of patients using opioids—have been studied little to date. 32 Rehabilitation strategies, including physical therapy, have been associated with reduced opioid use in patients with chronic noncancer pain when integrated into multimodal approaches, but studies on their effect as a stand-alone treatment are still limited. 72 Nevertheless, a systematic review of studies, mostly in primary care, showed that interprofessional collaboration was a promising strategy to improve appropriate opioid use and reduce opioid use disorder.…”

“…A recent scoping review identified strategies that may limit long-term opioid therapy. 32 Nonsteroidal anti-inflammatory drugs (NSAIDs), personalized opioid tapering protocols, educational strategies for patients and professionals, and multimodal and psychological strategies seem to have the greatest potential. Nevertheless, most of these strategies are supported by low-level evidence.…”

Team Approach: Use of Opioids in Orthopaedic Practice

“…Orthopaedic surgeons should also thoroughly assess current opioid intake before surgery to detect all patients exposed to opioids and take action before surgery, when possible. In this case, patients with pre-exposure to opioids may also benefit from further intervention before surgery 27,53,54 . For a patient who is being considered for reduction or elimination of opioids before surgery, it is essential to maintain communication between pain specialists and orthopaedic surgeons to facilitate a full and safe recovery after surgery.…”