Abstract
Background
Current research on opioid use within orthopedic surgery has focused on efforts to identify patients at risk for chronic opioid use. Studies addressing prevention of opioid misuse related to orthopedic care are lacking. Evidence-based interventions to reduce the reliance on opioids for post-operative pain relief will be a key component of any comprehensive institutional opioid policy.
Questions/Purposes
The purpose of this systematic review was to evaluate institutional strategies that reduce opioid administration or consumption after orthopedic surgery.
Methods
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, a search was conducted of the PubMed database for English-language articles that analyzed interventions by physicians, nurses, pharmacists, physical therapists, or other hospital staff to reduce post-operative opioid use or narcotic prescription amounts after surgery. Studies that contained objective outcome measures (i.e., no expert opinion articles) were selected. Investigations on the effect of pharmacologic adjuvants, cryotherapy, or regional nerve blockades on opioid use were excluded.
Results
The initial search yielded 6598 titles, of which 13 full-text articles were ultimately selected for inclusion in this systematic review. The review identified two major categories of interventions—patient-focused and provider-focused (e.g., physicians, nurses, physical therapists, pharmacists). Formal patient education programs were most effective in reducing opioid use. On the provider side, prescribing guidelines appear to decrease the overall number of pills prescribed, often without changes in patient satisfaction or requests for refills.
Conclusions
Researchers are just beginning to establish the most effective ways for institutions to reduce opioid use and promote responsible post-operative prescribing. Institutional prescribing guidelines, standardized bedside pain-management programs, and formal patient education curriculums are all evidence-based interventions that can achieve these goals. The available research also supports an interprofessional approach in any institutional opioid-reduction strategy.
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Francis Lovecchio, MD, Ajay Premkumar, MD, MPH, and Jeffrey G. Stepan, MD, MSc, declare that they have no conflicts of interest. Todd J. Albert, MD, reports receiving royalties from Zimmer Biomet, DePuy Synthes, JP Medical Publishers, Saunders/Mosby-Elseveir, and Thieme; owning stock in Gentis, Vital 5, Bonovo Orthopedics Inc., Biomerix, InVivo Therapeutics, Spinicity, Crosstrees Medical, Paradigm Spine LLC, Invuity, ASIP, PMIG, Pioneer, and Vertech; receiving personal fees from Nuvasive, Gentis, United Health Care, and Facet Link and non-financial support from Scoliosis Research Society; receiving salary from Hospital for Special Surgery and Weill Cornell Medical College and grants from Patient-Centered Outcomes Research Institute, ISSG, Alan L. and Jacqueline B. Stuart Spine Research Center, all outside the submitted work.
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Lovecchio, F., Premkumar, A., Stepan, J.G. et al. Fighting Back: Institutional Strategies to Combat the Opioid Epidemic: A Systematic Review. HSS Jrnl 15, 66–71 (2019). https://doi.org/10.1007/s11420-018-09662-y
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DOI: https://doi.org/10.1007/s11420-018-09662-y