- Open Access
Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review
BMC Musculoskeletal Disorders volume 23, Article number: 238 (2022)
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.
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.
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.
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.
Considering the pain induced by traumatic injuries and surgery, opioids are often used in the early recovery phase of patients facing these health issues . As such, a majority of trauma and surgical patients, particularly those who underwent orthopaedic procedures, still receive this analgesic at the time of hospital discharge and, alarmingly, up to 20% become chronic opioid users [2,3,4,5,6]. Moreover, the proportion can even reach 60% in those with a history of long-term opioid use [4, 7,8,9]. In this regard, several studies have documented risk factors for long-term opioid use in trauma and surgical patients, including prolonged duration of the initial opioid prescription [10,11,12,13], low income [9, 14], prior substance abuse [9, 14,15,16,17,18], use of specific medications (e.g., benzodiazepines, muscle relaxants, antidepressants) [9, 15, 18], psychologic comorbidities (particularly depression) [14, 15, 17,18,19,20], a history of chronic pain [15, 16, 18, 19, 21], and disease severity factors (e.g., complexity of fractures, invasiveness of spine surgery, number of surgeries, hospital length of stay) [17, 19, 20, 22].
The long-term use of opioids is associated with important individual and social negative consequences, which increase incrementally with the duration of opioid prescription . For example, patients using opioids in the context of persistent pain were shown to be two to five times more likely to suffer from drowsiness, sleep disorders, headaches and constipation, compared to those not taking such medication . Likewise, compared to nonopioid users, chronic users have greater psychological distress , greater interference with activities  and poorer quality of life [25, 26], without significantly improving their pain relief [2, 23, 25, 27]. Long-term opioid use is also associated with a 30% average rate of misuse (i.e., using opioids differently from how they are prescribed regardless of the presence of adverse events) . Even more disturbing, long-term prescription may ultimately lead patients to the illicit purchase of opioids or its derivatives (e.g., heroin) to meet the needs of their addiction or to compensate for a decrease in prescribed doses [29,30,31]. Taken together, these issues were acknowledged to contribute to the increasing number of overdoses and deaths associated with opioids [32, 33].
Hence, strategies that promote a judicious use of opioids while still providing pain relief are needed during patients’ recovery phase to prevent subsequent long-term negative impacts. Strategies to decrease the amount of opioids used in patients already on chronic therapy, such as tools to improve opioid prescription, education for patients and health professionals, and interprofessional collaboration, have shown promising results . However, little is known about available preventive strategies. Accordingly, we conducted a scoping review to systematically map the research done in this area, as well as to identify gaps in current knowledge on strategies to prevent chronic opioid use in adult trauma patients and in those who underwent an acute surgery for their injuries or a programmed orthopeadic surgery.
Methods and analysis
Our scoping review was performed according to recommendations [35,36,37] and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (Supplemental Digital File 1: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist) . The study protocol was recently published .
We included randomized controlled trials (RCTs), quasi-randomized, prospective and retrospective observational cohorts, cross-sectional, case–control studies and guidelines. Preventive strategies (pharmacological or non-pharmacological) initially needed to target the acute care trajectory (from hospital admission to 3 months postinjury or post-surgery) [40, 41] of adult patients (≥ 18 years old) after traumatic injuries or acute care surgery . We also included studies of elective orthopedic surgery patients, considering that the mechanisms of pain and likelihood of secondary opioid use are comparable to those of trauma patients that often have fractures . Comparators included placebo, any other intervention, or standard treatment. We first considered outcomes related to opioid use measured at ≥3 months after trauma or surgery, as this timeframe is indicative of a chronic use or long-term therapy [19, 20]. Nonetheless, some studies measured outcomes at 1 month and 6 weeks (medium-term therapy) , prompting us to report results at these time points as well. Since opioids are administered for pain management, we also included outcomes related to pain intensity. We did not apply any language restriction.
Concerns with regard to adverse events associated with prescribed opioids and initiatives to limit long-term opioid use [40, 45] started shortly before 2010. Therefore, we systematically searched studies published between January 2005 and September 2021 registered in the following databases: MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and ProQuest. As described in the published protocol , we also queried trauma and surgery, pain, government, and the websites of professional organisations. The reference lists of included articles were screened for any further eligible studies. Using Cochrane guidelines , we developed a rigorous systematic search strategy in collaboration with an information specialist. We used combinations of search terms under the themes of opioids and preventive strategies, including text terms and MESH (Medline) or EMTREE (Embase). We then adapted our search strategies for the other databases. The complete Medline search strategy is presented in Supplemental Digital File 2: Search Strategy in Medline.
Selection and data charting processes
All citations were managed in Covidence (Veritas Health Innovation, Melbourne, Australia). After a reliability test on two sets of 100 citations, pairs of reviewers (MB, CC, SG, OS) independently screened all identified citations using titles, abstracts and full texts. Disagreements were settled through discussion between reviewers and further discussed with an expert clinical researcher when needed (AT). Two data extraction forms were created: one for original studies and one for practice guidelines. They were tested on a sample of five studies and two guidelines, respectively, before pairs of reviewers (MB, CC, SG and OS) independently extracted data. The following information was retrieved from original studies: setting, population, risk factors for chronic opioid use (e.g. history of substance abuse, chronic pain, mood disorders) , study design, intervention(s), comparator(s), outcome measures and their timepoints, effectiveness of the strategy based on outcome measures of central tendency (i.e., mean) and frequency (rate, proportion) in intervention and comparator groups along with p-values for statistical significance. The same pairs of reviewers also extracted the following data from guidelines: setting, population and the recommended preventive strategies along with their level of evidence and the strength of their recommendations.
Data collation was conducted independently by two reviewers (CC and SG) and validated by a third reviewer (MB). Preventive strategies were organized into seven categories according to the type of preventive strategy as per pain management guidelines in trauma  and other fields [48, 49]: system-based, pharmacological, educational, multimodal and others, which included surgical procedures, alternative and psychological. The evidence from original studies was categorized based on whether or not findings favoured preventive strategies, as demonstrated by statistically significant results, set at p < 0.05 in the context of this review. We also compared the outcomes for the populations included in this scoping review (trauma, spine surgery, and elective orthopedic surgery) in relation to the categories of the preventive strategies. Results for the trauma population were not presented separately because of the similarities in the data compared to other populations and the fact that some categories or specific types of intervention contained very few studies. For guidelines, we described recommendations according to preventive strategy categories and their level of evidence specifying to which populations they applied. We reported levels of evidence and strength of recommendations according to the classification systems used in each of the guidelines.
Literature search and selection process
The searches identified 46,499 citations, including 15,840 duplicates of original studies and guidelines. As shown in Fig. 1, 391 studies met the inclusion criteria after initial screening. A total of 308 studies were excluded after the full-text review and are listed in Supplemental Digital File 3: Excluded full texts. The main reasons for exclusion at the full-text stage were: not measuring opioid use (n = 114), having only protocols available (n = 71) or wrong study design (n = 66). After final screening we included 66 studies [5, 50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114] and 20 [47, 48, 115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132] guidelines in the qualitative synthesis. These studies and guidelines were published between 2008 and 2021, with only one item (1.2%) published before 2010, 16 (18.6%) between 2010 and 2016 and 69 (80.2%) between 2017 and 2021.
Study and guideline characteristics
The key characteristics of the 66 included studies [5, 50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114] are detailed in Table 1: Study Characteristics, Description of Strategies and Outcomes. Most studies used a retrospective cohort (n = 35) [5, 52, 56, 60, 72,73,74, 78,79,80,81,82,83,84,85,86,87,88,89, 91,92,93,94, 97,98,99, 101,102,103,104,105, 108, 109, 111, 112], a randomized controlled trial (RCT) (n = 24) [50, 51, 53,54,55, 57, 59, 61, 62, 65,66,67,68,69,70,71, 75, 76, 95, 100, 106, 107, 113, 114] or a prospective cohort (n = 7) [58, 63, 64, 77, 90, 96, 110] design. Almost all the studies were conducted in the U.S. (n = 58) [5, 50,51,52,53,54,55,56,57, 59,60,61, 63, 67,68,69,70,71,72,73,74, 77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99, 101,102,103,104,105,106,107,108,109,110,111,112,113,114].
The sample sizes ranged from 40  to 120,080  participants (mean = 5, 094, median = 230) with an average age between 20  and 75  years, but greater than 55 years in the majority of studies (n = 49). More than 60% of the studies (n = 41) had more than 50% of females (range from 1.0 to 81.0%). Most of the selected studies (62.1%) focused on the elective orthopaedic surgery population who underwent procedures to the limbs [50, 51, 54, 56,57,58,59, 61, 62, 64, 65, 67, 68, 70,71,72,73,74, 76, 78, 82, 84, 88,89,90,91,92, 95, 102,103,104,105,106,107,108,109,110,111,112,113,114]. The remaining studies targeted trauma populations (18.2%) [5, 63, 66, 75, 87, 93, 94, 96, 98,99,100,101] or a mix of trauma and elective orthopaedic surgical patients (12.1%) [52, 53, 55, 77, 79, 80, 86, 97], and patients who underwent spine surgery performed by orthopaedic or neurosurgeons (7.6%) [60, 69, 81, 83, 85].
Risk factors for chronic opioid use (e.g., previous opioid use, benzodiazepine use, substance abuse, mental health disorder, chronic pain) were measured in close to 70% of studies [5, 50, 51, 56,57,58, 61, 63, 64, 67, 68, 72,73,74, 78, 79, 82,83,84,85,86,87,88,89, 92,93,94,95, 97,98,99,100, 102,103,104,105,106,107,108,109,110,111,112,113,114] (Supplemental Digital File 4: Risk factors for chronic opioid use in included studies by types of strategies). The main risk factors involved were depression/anxiety or associated medication use [51, 53, 56, 57, 63, 64, 72,73,74, 78, 79, 82, 83, 85,86,87,88,89, 92, 97, 100, 102, 104, 107, 109, 112, 114], and prior opioid use [5, 53, 57, 58, 61, 63, 64, 67, 68, 73, 74, 78, 82, 83, 85,86,87,88,89, 95, 97,98,99,100, 102,103,104, 107,108,109, 111, 113, 114]. Amongst studies that included patients at risk for chronic opioid use, nearly 60% [51, 53, 63, 64, 72, 74, 78, 82, 83, 85, 89, 94, 95, 97,98,99,100, 102,103,104, 106, 107, 109, 110, 112,113,114] included a sample with a risk ≥25%, but only 20% [74, 78, 83, 95, 100, 104, 107, 110, 113] included a sample with a risk of ≥50% or more.
As described in Table 1: Study Characteristics, Description of Strategies and Outcomes, selected studies were divided in seven categories, according to the type of strategy assessed. Among system-based strategies, we identified 22 studies on hospital-based protocols to limit or improve opioid prescriptions (n = 13) [77,78,79,80,81,82,83, 89, 90, 92, 96, 97, 102] or formal government regulation in some U.S. states to limit opioid prescriptions (n = 9) [85,86,87,88, 91, 93, 103,104,105]. Among pharmacological strategies, we identified 18 studies [62,63,64,65,66,67,68,69,70,71,72,73,74,75,76, 94, 98, 99, 106], which mainly focused on the effect of anesthetic agents administered through regional anesthesia (n = 8) [62, 65, 70, 73, 74, 94, 98, 99] and the impact of medication on the central nervous system [63, 66, 67, 69] (n = 4) and opioid use. The educational strategies comprised seven studies on strategies aimed at providing patient information on the adequate use of opioids (n = 6) [5, 50, 51, 53, 100, 107] or aimed as a reminder to professionals on opioid prescribing guidelines (n = 1) . The multimodal strategies included eight studies testing strategies on multiple analgesic regimens or a combination of pharmacological and non-pharmacological strategies [56,57,58, 68, 84, 101, 108, 110] and a transitional pain service . Finally, five studies focused on the effect of surgical techniques (e.g., different surgical approaches [59,60,61, 111]) or inpatient vs. outpatient surgery ; two on an alternative pain management strategy (i.e., acupuncture) [54, 55], and three on a psychological strategy (i.e., Acceptance and Commitment Therapy , motivational interviewing  or mindfulness .
We identified three outcomes related to opioid use. The most commonly measured outcome was the quantity of opioids in morphine equivalent doses (MEDs) (n = 44) [53, 55,56,57,58,59, 61, 63, 68, 70, 72, 74,75,76,77, 79,80,81,82,83,84,85,86,87, 89,90,91,92,93, 96,97,98,99,100,101,102,103,104,105,106,107,108, 110, 111], generally measured at 6 weeks or 1, 3 and 6 months. The proportion of patients using opioids was the second most frequently used outcome measure in the selected studies (n = 25) [5, 53, 57, 58, 62,63,64,65, 67, 69, 72, 73, 78, 81, 86, 94, 96, 100, 101, 105, 107, 109, 112, 114, 134] and this evaluation was often conducted at 3 (n = 13) [5, 53, 57, 62, 63, 65, 72, 81, 94, 100, 105, 112, 114] and 6 months (n = 6) [64, 67, 78, 101, 114]. The least frequently measured outcome was the proportion of patients who received an opioid prescription refill (n = 18) [57, 68, 79,80,81, 83, 89,90,91,92, 96, 97, 102, 103, 105, 108, 110, 111] at 1 and 3 months. None of the studies measured illicit opioid use or opioid diversion (i.e., opioid diverted from siblings who have legitimate prescriptions). Data came from patient records or clinical-administrative databases (n = 27) [5, 60, 73, 74, 78,79,80,81, 83,84,85,86,87,88,89, 91, 94, 98, 101,102,103,104,105, 108, 110, 112, 114], or a combination of these methods, and from patient self-report (n = 17) [53, 55, 58, 62, 63, 65, 68, 71, 72, 77, 82, 90, 96, 100, 107, 109, 113] in many studies. The remaining studies measured outcomes from self-reported data only (n = 5) [50, 54, 67, 69, 95] or did not clearly describe the data source (n = 17) [51, 52, 56, 57, 59, 61, 64, 66, 70, 75, 76, 92, 93, 97, 99, 106, 111]. Regarding the proportion of trauma and orthopaedic surgical patients still using opioids at follow-up, the proportion of patients using opioids at 3 months as reported in some studies varied from 12 to 30% in trauma patients [63, 86, 100] and from 10 to 50% in elective orthopaedic surgical patients [67, 78, 95, 107, 112] presenting risk factors for chronic opioid use. One study also reported proportions of almost 70% for patients with a history of chronic opioid use at 12 months in the context of elective orthopaedic surgery . Two studies concerning trauma populations documented proportions of 20 to 40% for patients with no documented risk factors at 3 months [5, 94] and the proportion decreased to 15% at 6 months . For other studies conducted mostly in non-trauma patients without or with minimal risk factors (≤ 25% of the sample), the proportion varied from 0% (intervention group only) to 25% at 3 months [57, 65, 105, 107, 109, 114].
As shown in Table 2: Study Characteristics, Description of Strategies and Outcomes, most guidelines came from the U.S. (n = 13) [47, 48, 115, 118,119,120,121,122,123, 126, 128, 130, 131]. They provided recommendations to prevent chronic opioid use in the following populations: surgery in general (20%) [48, 116, 117, 123], orthopaedic surgery (35%) [118, 124, 125, 127, 128, 130, 132], trauma (25%) [47, 122, 126, 129, 131], a combination of trauma and orthopaedic surgery (10%) [119, 120] as well as general and orthopaedic surgery (5%) , or patients with acute pain (5%) . Guideline recommendations were classified according to the following categories: system-based, pharmacological, educational and multimodal.
Evidence on preventive strategies
As described in Table 1: Study Characteristics, Description of Strategies and Outcomes, this category contains 19 retrospective [77,78,79,80,81,82,83, 85,86,87,88,89, 91,92,93, 97, 102,103,104,105] and three prospective cohort studies [77, 90, 96], whose comparators were all pre-intervention data.
Most studies on hospital-based and government regulation initiatives limiting the prescription of opioids showed a significant decrease in MED taken by opioid-naïve and non-opioid naïve patients at 1 month after trauma [86, 87, 93] and elective orthopeadic surgery [85, 88, 90, 91, 104], and mainly in opioid-naïve patients up to 3 months in these two populations [82, 86, 92, 102,103,104,105]. Also, regulation on prescription limits led to mixed results on opioid refills, with a significant decrease [80, 82, 103, 105] or increase [88, 90, 91, 102] after trauma and elective orthopaedic surgery. Strategies related to the implementation of prescription guidelines did not lead to a significant decrease in MED, opioid refills or the proportion of patients using opioids after trauma at 1 month [77, 96, 97]. However, strategies based on individualized opioid tapering protocols, which were not evaluated in the context of trauma, led to a significant reduction in opioid use in MED 6 weeks  and 6 months after spine surgery . About a third of patients were using opioids preoperatively in these studies [83, 89]. It is interesting to note that most studies performed in elective orthopaedic surgical context had more than 25% of patients at high risk of chronic opioid use (i.e., prior opioid use, alcohol abuse or psychological comorbidities) [78, 82, 83, 85, 89], all of which demonstrated at least one statistically significant result favouring the group that received a preventive strategy.
System-based strategies were also frequently addressed in practice guidelines (Table 2: Study Characteristics, Description of Strategies and Outcomes). However, recommendations were mostly based on expert consensus or low-quality evidence. Guidelines strongly emphasized the importance of an early assessment of patients’ risk factors in order to plan for the required follow-up [48, 115,116,117, 121, 131]. Similarly, communication between professionals was recommended in order to establish the required follow-up, to avoid multiple prescribers, and to refer patients to specialized resources in a timely manner after trauma and orthopaedic surgery, particularly those misusing opioids or with a history of substance abuse [47, 115,116,117,118,119, 130].
This category includes ten RCTs [62, 65,66,67, 69,70,71, 75, 76, 106], six retrospective [72,73,74, 94, 98, 99] and two prospective cohort studies [63, 64] (Table 1: Study Characteristics, Description of Strategies and Outcomes). Most studies used a placebo (n = 9) [62, 66, 67, 69, 71, 74,75,76, 106] or no intervention (n = 7) [63, 64, 72, 73, 94, 98, 99] as comparators. Studies comparing the use of regional anesthesia to general anesthesia in trauma patients, showed an increase in MED at 3 months post-injury [98, 99]. One study evaluating the impact of recreational cannabis use during the recovery of trauma patients showed a significant increase in MED at 6 months and in the duration of opioid use, compared to patients who never used this drug . Among the studies that analyzed the effect of nerve blocks as a preventive strategy [62, 65, 70, 73, 74, 94], compared to usual care or placebo, none showed a significant decrease in MED [70, 74] or in the proportion of opioid-naïve and non-opioid naïve patients using opioids [62, 65, 73, 94] in the trauma or orthopaedic surgical populations at 3 months and beyond. Likewise, drugs with an impact on the central nervous system (e.g., gabapentinoids, antidepressants) [66, 67, 69] were not significantly associated with a reduction in opioid use in patients with burn injury  or who underwent spine  or elective orthopaedic surgery . Three RCTs [71, 76, 106] on the regular use of postoperative NSAIDs compared to placebo showed a significant decrease in opioid use up to 12 months after an elective orthopaedic surgical procedure (i.e., total knee arthroplasty or shoulder surgery) regardless of whether or not opioids were taken prior to surgery. Beta blockers have also been associated with a reduction in MED and in the proportion of patients using opioids at 1 month after an elective orthopaedic surgery in a retrospective study conducted in a population with a large proportion of patients with a history of depression .
Many guidelines (Table 2: Study Characteristics, Description of Strategies and Outcomes) emphasized the safety of opioid prescriptions [47, 116,117,118, 120, 121, 125, 127, 129, 131, 132] in trauma and surgical populations. Those guidelines recommended using opioids only when necessary [117, 118, 127, 129, 131, 132], at the lowest effective dose [47, 117, 118, 131], avoiding dose escalation [117, 120], and using opioids for the shortest period of time possible [47, 118, 131]. These recommendations were associated with moderate to high levels of evidence in trauma  and in patients on preoperative opioid use . The use of NSAIDs as a strategy to limit long-term opioid use was rated as high-quality evidence in one guideline on elective orthopaedic procedures . Guidelines also specified that opioid prescriptions must be tailored to the patient’s condition [47, 48, 116, 119, 121, 126, 131]. However, these recommendations were mainly based on expert consensus.
This category comprises three RCTs [50, 51, 53, 100, 107] and two retrospective cohort studies [5, 52], the majority of which used standard educational programs [50,51,52,53, 100, 107] or no educational intervention  as comparators (Table 1: Study Characteristics, Description of Strategies and Outcomes). Many studies evaluating educational strategies reported positive outcomes after trauma and orthopaedic surgery. MED was measured in two studies [53, 100] and favoured (one study with significant result  and one small pilot study without significant results ) the group of patients who received a formal education program compared to usual care, at 6 weeks and 3 months after an injury. These outcomes were achieved despite the presence of more than 25% of patients at high risk (i.e., history of substance abuse, psychological comorbidities, opioid use before the injury) for long-term opioid use in the study population. However, another study conducted in elective orthopaedic surgery showed a significant decrease in the proportion of opioid dependence (i.e., 6 opioid prescriptions from the date of surgery) only in opioid-naïve patients . Time to opioid cessation was measured in two studies [50, 53] and was significantly lower in patients who received educational strategies after traumatic injuries  and elective orthopaedic surgery . Finally, an educational program for hand surgeons led to a 20% significant decrease in prescribed opioids at 3 months .
Guidelines also provided recommendations on educational strategies for patients and health care professionals [47, 48, 116, 118, 121, 127, 131, 132] after trauma and surgery, but the majority were based on expert consensus or lower quality evidence (Table 2: Study Characteristics, Description of Strategies and Outcomes). These recommendations focused on educating patients and/or families about the risks and benefits of opioids [121, 131], different pain management methods to limit opioid use [116, 118, 121], and information on storing and returning medications after surgery [116, 131]. They also provided advice on using a monitoring and tapering opioids plan [48, 118].
This category includes two RCTs [57, 68], two prospective [58, 110] and five retrospective cohort study [56, 84, 101, 108, 109] comparing different types of multimodal regimens to usual treatment (Table 1: Study Characteristics, Description of Strategies and Outcomes). Although less numerous, multimodal strategies were also associated with several favourable outcomes after trauma and elective orthopaedic surgery. For example, studies on multimodal analgesic regimens with minimal opioid use showed significant reductions in MED but not in the proportion of opioid users at 6 months after trauma  compared to patients who received a regimen mainly based on opioids. It should be noted that risk factors for opioid use were not specified in this study and that only 3% of patients were still taking opioids in both groups at 6 months. Still, for the elective orthopaedic population, a significant decrease in MED was reported up to 3 months in opioid-naïve and non-opioid naïve patients [57, 68, 84, 110]. Moreover, the proportion of opioid-free patients at 6 weeks increased significantly for those who received an enhanced recovery after surgery (ERAS) program, consisting of pharmacological and non-pharmacological strategies for pain management, compared to those who did not after an elective orthopaedic surgery . Such results were also observed after the implementation of a transitional multidisciplinary service in opioid-naïve and non-opioid naïve veterans . A large proportion of this population had a history of mental health disorders. Finally, studies demonstrated a significant reduction in MED at 6 weeks to 3 months by adding cryoneurolysis to multimodal analgesic regimen in an elective orthopaedic surgery population without risk factors for chronic opioid use [56, 108].
Most guidelines [47, 48, 116,117,118, 120, 122, 123, 125, 128, 130,131,132] recommended a multimodal analgesia plan (i.e., acetaminophen, NSAIDs) as a first line of treatment to limit opioid use in trauma and surgical patients, based on moderate to high quality evidence (Table 2: Study Characteristics, Description of Strategies and Outcomes). A few guidelines [48, 120, 121] also recommend the addition of anticonvulsants (e.g., pregabalin) under specific conditions, such as neuropathic pain. Several guidelines also propose non-pharmacological strategies [116, 117], including complementary and integrative health approaches (e.g., acupuncture, mindfulness meditation) , transcutaneous electrical nerve stimulation (TENS) , cognitive behavioural therapy, physical activity or behavioural health interventions , as well as cooling and compression techniques . Those strategies were rated as low-quality evidence, except physical activity, behavioural activation and TENS, which had moderate quality evidence in the trauma and post-surgical context, respectively.
Others (surgical, alternative, psychological)
The remaining ten studies included seven RCTs [54, 55, 59, 61, 95, 113, 114] and three retrospective cohort study [60, 111, 112]. Four studies compared two types of surgery (inpatient or outpatient) with one another [59,60,61, 111]; one opioid use following Outpatient versus Inpatient Total Joint Arthroplasty ; three psychological interventions (Acceptance and Commitment Therapy, Mindfulness, Motivational interviewing with guided opioid tapering support) to information [95, 113]; and the last two evaluated the efficacy of acupuncture compared to usual care  or placebo . All studies involved an orthopaedic surgical population except for one study on acupuncture that involved trauma patients. None of the interventions described in these studies [54, 55, 59,60,61, 95, 111, 112] showed a significant reductions in opioid use excepting one study evaluating the impact of an outpatient surgical intervention and two studies that assessed psychological strategies (mindfulness therapy and motivational interviewing combined with opioid tapering support). These studies demonstrated a statistically significant decrease in the proportion of new opioid persistent use , opioid use at 1 month  and an earlier return to previous opioid use  in elective orthopaedic surgery patients. A large proportion of these patients had psychological comorbidities and a history of preoperative opioid use particularly when psychological interventions were tested. We identified no guidelines recommendations on these intervention categories used as a single therapy.
The effect of chronic opioid use prevention strategies on pain management
We analyzed study findings to determine if reductions in opioid use were associated with increased pain intensity. Near half of included studies (n = 30) assessed pain intensity concomitantly with strategies aimed at preventing chronic opioid use [53,54,55, 57,58,59,60,61,62, 64,65,66,67,68, 70, 71, 74,75,76, 78, 84, 90, 95, 96, 100, 106, 107, 110, 113, 114]. There was no significant difference between the groups that received a preventive strategy compared to the control groups for most of these studies, while seven indicated a significant decrease [57, 62, 65, 66, 71, 107, 113] and one a significant increase .
Our scoping review provides a comprehensive overview of the existing strategies to prevent long-term opioid use in patients who have undergone trauma or orthopeadic surgery while identifying future research avenues. More than 80% of studies and guidelines were published after 2017, reflecting the marked interest in countering the opioid crisis from the middle of the last decade. This concern is also highlighted by the fact that more than a third of the studies evaluated strategies to legislate or guide opioid prescriptions. Most of the studies were conducted in patients who had orthopaedic surgery and only a few were performed specifically in the trauma population. However, outcomes related to the different categories of strategies were comparable across these two types of study populations, even though elective orthopedic surgery patients were often using opioids preoperatively. Less than half of studies were high-quality evidence (i.e., RCTs). Retained studies evaluated system-based, pharmacological, educational, multimodal, surgical, alternative and psychological strategies. The most commonly used outcome measure was MED and a few studies documented the proportion of patients still using opioids at 3 months and beyond, which was considerably more important in those with risk factors. Data were mostly collected from patient records and clinical-administrative databases, but close to a third of studies did not provide information on the data source. Also, very few studies examined patient-reported outcomes and none measured the illicit use of opioids or opioid diversion that might be associated with a decrease in prescriptions [29, 31].
System-based strategies were regularly associated with long-term reductions in opioid use with mostly favourable results [78, 82, 83, 86, 102, 104, 105]. Such findings might indicate that hospital-based protocols and guidelines provide information on standards of practice and can be used as reminder mechanisms, enhancing the judicious prescription of opioids . Legislations on prescribing limits were mainly effective with regard to the reduction of MED used by patients in the acute phase [85,86,87,88, 91, 93, 103, 104] but the effect was not sustained in the chronic phase in non-opioid naïve patients [87, 88, 91]. Prescribing limits enacted by several U.S. states have been associated with mitigated findings [136,137,138]. This may be caused by the fact that this strategy does not acknowledge the difference between minimally painful conditions and more painful conditions, and that it is not suitable for patients who were previously using opioids . This more restrictive strategy may also lead patients to turn to the illicit market if pain remains a significant problem [31, 140]. For patients with risk factors for long-term opioid use, a more individualized approach to prescribing may be necessary as demonstrated by the positive results obtained in studies evaluating tailored tapering protocols [83, 84].
Regarding pharmacological strategies, only NSAIDs [71, 76] and beta blockers in specific orthopaedic surgical procedures limited prolonged opioid therapy. Ketamine has been the subject of several studies, but none of them were included in this review because opioid use was measured only in the short term (Supplemental Digital File 3: Excluded full texts). Interestingly, analgesics administered through nerve blocks and other drugs were mainly prescribed intraoperatively and in the immediate postoperative period, while NSAIDs [71, 76] and beta blockers  were used by patients for 6 weeks after surgery. Pregabalin, administered for approximately the same time period, did not lead to a decrease in MED in trauma patients. Nevertheless, this result was from a small RCT which was not powered to find a statistically significant difference in opioid use between groups . Non-medical cannabis use also resulted in increased opioid consumption over a longer time period. However, despite its potential analgesic properties, the use of cannabis without medical supervision may indicate a propensity for substance abuse [141, 142]. Thus, extending medical prescriptions of co-analgesia beyond hospital discharge may be a potential solution to limit the long-term consumption of opioids. Such an approach will need to balance the risk-benefit of analgesics, such as NSAIDs which is contraindicated in patients with cardiovascular and renal diseases, and the risk of complications, which includes delayed bone union or non-union with more than 2 weeks of treatment [143,144,145,146].
Although fewer in number, studies on educational and multimodal preventive strategies also showed promising findings. Educational strategies included formal education to patients, with or without a follow-up, on how to use opioids and on the potential adverse events associated with prolonged therapy [5, 50, 53, 100, 106]. This indicates that some patients are responsive to advice provided by health care professionals on the risks associated with opioid use. The implementation of an educational assistive device to be used as a memory prompt about guidelines also helped health care professionals prescribe less opioids . This concurs with the findings from a recent systematic review showing that interventions providing support during clinical decision can reduce low value practices . With regard to multimodal strategies, those associated with positive outcomes were based on the concomitant use of several analgesics (e.g., acetaminophen, gabapentin, NSAID and opioid) [57, 68, 84, 101, 110], sometimes in combination with non-pharmacological strategies such as physiotherapy  and cryotherapy [56, 108] as well as the involvement of interdisciplinary teams . In addition, the use of psychological strategies involving mindfulness  and motivational interviewing  have been shown to be beneficial in patients at risk for long-term opioid use following orthopaedic elective surgery. Such approaches were shown to improve pain management after musculoskeletal injuries [148, 149] and could, therefore, contribute to a decrease in opioid use. Conversely, although understudied, non-pharmacological strategies, such as the use of acupuncture were not conclusive [54, 55].
The evidence described in this review is largely similar to that of a recent systematic review on strategies to improve the judicious use of opioids in patients already on chronic therapy . This review identified the following strategies as the most promising: clinical practice changes, such as a tool to improve opioid prescription practices, public campaigns, including the development of opioid prescribing guidelines, education for patients and health professionals, and collaborative work involving interprofessional and interdisciplinary teams . However, although some strategies to prevent long-term opioid use after trauma and orthopaedic surgery were associated with favourable outcomes in terms of opioid use, the quality of evidence to support them remains low as highlighted in several recommendations from practice guidelines. This, except for recommendations on pharmacological strategies to use minimal opioids in trauma , multimodal pain management strategies  and NDSAIDs in orthopedic surgery [127, 132]. Several systematic reviews on opioid misuse in the context of chronic pain also concluded that there is a shortage of high-quality studies on strategies to promote the judicious use of opioids [150,151,152]. Many aspects of this complex issue will require further studies to enable the implementation of efficient and safe strategies in the health care setting. For example, even though the trauma population shares similarities with the surgical population, their care trajectories can lead to important gaps and setbacks in opioid weaning. Only a few hospitals are designated as trauma centers, so trauma patients may be sent to recover in regional hospitals while many may also necessitate rehabilitation before returning home and being monitored in their community . Hence, strategies that target judicious opioid reduction in each phase of the trauma patient’s care trajectory, and communication mechanisms between health professionals involved in these different phases should be developed and evaluated in future studies. Furthermore, considering that the prescription of opioids has been identified as a precipitating factor in the illicit use of this drug and its derivatives, such as heroin [29, 30], it is important to develop strategies that take this risk into consideration. To this end, strategies that do not aim at stopping opioids at all costs but according to specific indicators, such as pain interference with activities, and that include patient follow-up, particularly those with risk factors for addiction, should be considered [140, 154].
In addition to reliable data on opioid use, future trials on the effectiveness of preventive strategies should focus on patient relevant outcomes such as pain, quality of life or daily function. Adverse events related to opioid use (e.g., intoxications, drowsiness, constipation, psychological distress), opioid diversion, illicit drug use as well as direct costs (e.g., health care service utilization, cost per quality-adjusted life-year) and indirect costs (e.g., lost in productivity) should also be measured. Likewise, the effectiveness of strategies in high-risk patients needs further confirmations considering that they use opioids in the long-term in a greater proportion, making them those who could benefit the most from preventive measures. Finally, subgroup analyses could help determine the role of biological sex and gender determinants, as well as socioeconomic status on the effect of preventive strategies [155, 156].
Strengths and limits
This study presents a rigorous, comprehensive review of the evidence on strategies aimed at preventing chronic opioid use. Several trauma and surgery stakeholders from various disciplines (e.g., surgeons, physicians specialized in pain, psychologists, nurses, pharmacists and physiotherapists) and researchers specialized in trauma, orthopaedic surgery and/or mental health and addiction contributed to the analysis and interpretation of findings. These experts also identified research needs to decrease the knowledge gap regarding preventive strategies in order to determine their effectiveness and promote their implementation in clinical practice.
This study also has some limitations. First, for feasibility reasons, we restricted the review to studies and guidelines published since 2005. Hence, we may have missed research evidence published before this date. However, most studies on limiting opioid prescribing emerged after 2005, as illustrated by the fact that we only found studies or guidelines published since 2008 and beyond and only one item before 2010. Second, some types of preventive strategies, including alternative, have not been the subject of many large-scale studies, which limits the conclusions that can be drawn on their potential benefits. Third, significant findings on long-term opioid use are limited since the outcomes were sometimes measured no longer than 1 month after trauma or surgery. Nonetheless, we believe that data on medium-term use provide valuable information on opioid tapering trends extending after this period. Fourth, this review aimed to provide an overview of the research strategies to prevent chronic opioid use and the methodological quality of studies and guidelines was not assessed. Hence, although positive and significant results were identified for a few strategies, with some guidelines giving specific levels of evidence with regard to these strategies, findings must be interpreted with caution. Moreover, we do not know if reductions in prescribed opioid use for the studied strategies led patients to obtain this drug through non-legal means. In any case, findings highlight the need to conduct further studies to confirm the effectiveness and safety of the described preventive strategies. As well, to identify strategies to target for future research, we will need to determine those estimated to be the most feasible and useful by health care providers through a practice survey. This step will be included in a research program on the development and evaluation of strategies aimed at preventing long-term opioid use in high-risk trauma patients.
Our scoping review gives an overview of the existing preventive strategies for chronic opioid use in patients who have undergone trauma and orthopaedic surgery. Some strategies, such as the implementation of individualized opioid tapering protocols, multimodal approaches, and educational strategies were promising. However, the low-quality evidence of these strategies clearly demonstrates that continued development and testing is needed to determine their preventive effect. In order to do so, future studies should target patients at high risk of chronic opioid use, evaluate patient-relevant and social outcomes, as well as measure opioid illicit use. More research on trauma patients who have specific care trajectories and on the potential risk of patients turning to illegitimate drug use is also required. Finally, special attention should be given to the feasibility and acceptability of the preventive strategies in complex trauma systems to facilitate their implementation in clinical practice.
Availability of data and materials
All data generated or analysed during the current study are included in this article and its supplementary information files.
Canadian Pain Society. Position statement on opioid analgesics in pain management--2015 update. Pain Res Manag. 2015;20(6):287.
Trevino CM, deRoon-Cassini T, Brasel K. Does opiate use in traumatically injured individuals worsen pain and psychological outcomes? J Pain. 2013;14(4):424–30.
Al Dabbagh Z, Jansson K, Stiller CO, Montgomery S, Weiss RJ. No signs of dose escalations of potent opioids prescribed after tibial shaft fractures: a study of Swedish National Registries. BMC Anesthesiol. 2014;14:4.
Holman JE, Stoddard GJ, Higgins TF. Rates of prescription opiate use before and after injury in patients with orthopaedic trauma and the risk factors for prolonged opiate use. J Bone Joint Surg Am. 2013;95(12):1075–80.
Holman JE, Stoddard GJ, Horwitz DS, Higgins TF. The effect of preoperative counseling on duration of postoperative opiate use in orthopaedic trauma surgery: a surgeon-based comparative cohort study. J Orthop Trauma. 2014;28(9):502–6.
Callinan CE, Neuman MD, Lacy KE, Gabison C, Ashburn MA. The initiation of chronic opioids: a survey of chronic pain patients. J Pain. 2017;18(4):360–5.
Al Dabbagh Z, Jansson K, Stiller CO, Montgomery S, Weiss RJ. Long-term pattern of opioid prescriptions after femoral shaft fractures. Acta Anaesthesiol Scand. 2016;60(5):634–41.
Weiss RJ, Montgomery SM, Stiller C-O, Wick MC, Jansson K-Å. Long-term follow-up of opioid use in patients with acetabular fractures. Inj Extra. 2012;43(7):49–53.
Pagé MG, Kudrina I, Zomahoun HTV, Croteau J, Ziegler D, Ngangue P, et al. A systematic review of the relative frequency and risk factors for prolonged opioid prescription following surgery and trauma among adults. Ann Surg. 2020;271(5):845–54.
Durand Z, Nechuta S, Krishnaswami S, Hurwitz EL, McPheeters M. Prevalence and risk factors associated with long-term opioid use after injury among previously opioid-free workers. JAMA Netw Open. 2019;2(7):e197222.
Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 2014;30(7):557–64.
Reyes AA, Canseco JA, Mangan JJ, Divi SN, Goyal DKC, Bowles DR, et al. Risk factors for prolonged opioid use and effects of opioid tolerance on clinical outcomes after anterior cervical discectomy and fusion surgery. Spine (Phila Pa 1976). 2020;45(14):968–75.
Shah AS, Blackwell RH, Kuo PC, Gupta GN. Rates and risk factors for opioid dependence and overdose after urological surgery. J Urol. 2017;198(5):1130–6.
von Oelreich E, Eriksson M, Brattström O, Sjölund KF, Discacciati A, Larsson E, et al. Risk factors and outcomes of chronic opioid use following trauma. Br J Surg. 2020;107(4):413–21.
Lavoie-Gagne O, Nwachukwu BU, Allen AA, Leroux T, Lu Y, Forsythe B. Factors predictive of prolonged postoperative narcotic usage following orthopaedic surgery. JBJS Rev. 2020;8(6):e0154.
Pugely AJ, Bedard NA, Kalakoti P, Hendrickson NR, Shillingford JN, Laratta JL, et al. Opioid use following cervical spine surgery: trends and factors associated with long-term use. Spine J. 2018;18(11):1974–81.
Lapidus JB, Santosa KB, Skolnick GB, Som A, Cho GJ, Waljee JF, et al. Opioid prescribing and use patterns in postsurgical facial trauma patients. Plast Reconstr Surg. 2020;145(3):780–9.
Wu L, Li M, Zeng Y, Si H, Liu Y, Yang P, et al. Prevalence and risk factors for prolonged opioid use after total joint arthroplasty: a systematic review, meta-analysis, and meta-regression. Arch Orthop Trauma Surg. 2021;141(6):907–15.
Mohamadi A, Chan JJ, Lian J, Wright CL, Marin AM, Rodriguez EK, et al. Risk factors and pooled rate of prolonged opioid use following trauma or surgery: a systematic review and meta-(regression) analysis. J Bone Joint Surg Am. 2018;100(15):1332–40.
Schoenfeld AJ, Nwosu K, Jiang W, Yau AL, Chaudhary MA, Scully RE, et al. Risk factors for prolonged opioid use following spine surgery, and the association with surgical intensity, among opioid-naive patients. J Bone Joint Surg Am. 2017;99(15):1247–52.
Lawal OD, Gold J, Murthy A, Ruchi R, Bavry E, Hume AL, et al. Rate and risk factors associated with prolonged opioid use after surgery: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(6):e207367.
Sabesan VJ, Chatha K, Goss L, Ghisa C, Gilot G. Can patient and fracture factors predict opioid dependence following upper extremity fractures?: a retrospective review. J Orthop Surg Res. 2019;14(1):316.
Deyo RA, Smith DH, Johnson ES, Donovan M, Tillotson CJ, Yang X, et al. Opioids for back pain patients: primary care prescribing patterns and use of services. J Am Board Fam Med. 2011;24(6):717–27.
Tucker HR, Scaff K, McCloud T, Carlomagno K, Daly K, Garcia A, et al. Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review. Br J Sports Med. 2020;54(11):664.
Desai R, Hong YR, Huo J. Utilization of pain medications and its effect on quality of life, health care utilization and associated costs in individuals with chronic back pain. J Pain Res. 2019;12:557–69.
Dillie KS, Fleming MF, Mundt MP, French MT. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med. 2008;21(2):108–17.
Huang A, Azam A, Segal S, Pivovarov K, Katznelson G, Ladak SS, et al. Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service. Pain Manag. 2016;6(5):435–43.
Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569–76.
Coffin PO, Rowe C, Oman N, Sinchek K, Santos GM, Faul M, et al. Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLoS One. 2020;15(5):e0232538.
Gaines TL, Wagner KD, Mittal ML, Bowles JM, Copulsky E, Faul M, et al. Transitioning from pharmaceutical opioids: a discrete-time survival analysis of heroin initiation in suburban/exurban communities. Drug Alcohol Depend. 2020;213:108084.
Jones W, Vojtila L, Kurdyak P, Fischer B. Prescription opioid dispensing in Canada: an update on recent developments to 2018. J Pharm Policy Pract. 2020;13:68.
Gomes T, Khuu W, Martins D, Tadrous M, Mamdani MM, Paterson JM, et al. Contributions of prescribed and non-prescribed opioids to opioid related deaths: population based cohort study in Ontario, Canada. BMJ. 2018;362:k3207.
Centers for Disease Contrrol - National Center for Health Statistics. National vital statistics system, mortality. Atlanta: CDC; 2021. Available from: https://www.cdc.gov/drugoverdose/data/analysis.html#tabs-2-4
Furlan AD, Carnide N, Irvin E, Van Eerd D, Munhall C, Kim J, et al. A systematic review of strategies to improve appropriate use of opioids and to reduce opioid use disorder and deaths from prescription opioids. Can J Pain. 2018;2(1):218–35.
Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
Daudt HM, van Mossel C, Scott SJ. Enhancing the scoping study methodology: a large, inter-professional team's experience with Arksey and O’Malley’s framework. BMC Med Res Methodol. 2013;13:48.
Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69.
Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.
Bérubé M, Moore L, Lauzier F, Côté C, Vogt K, Tremblay L, et al. Strategies aimed at preventing chronic opioid use in trauma and acute care surgery: a scoping review protocol. BMJ Open. 2020;10(4):e035268.
Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–30.
Von Korff M, Saunders K, Thomas Ray G, Boudreau D, Campbell C, Merrill J, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24(6):521–7.
Ball CG, Hameed SM, Brenneman FD. Acute care surgery: a new strategy for the general surgery patients left behind. Can J Surg. 2010;53(2):84–5.
American College of Surgeons Committee on Trauma. The annual report of the National Trauma Data Bank (NTDB) 2016. Chicago: American College of Surgeons; 2016.
Els C, Jackson TD, Kunyk D, Lappi VG, Sonnenberg B, Hagtvedt R, et al. Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2017;10(10):Cd012509.
National Opioid Use Guideline Group (NOUGG). Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. 2010.
Lefebvre C, Manheimer E, Glanville J. Searching for studies. In: Cochrane handbook for systematic reviews of interventions. Chichester: Wiley; 2011. Version 5.1 [updated 2011]. Available from: http://handbook.cochrane.org/.
Hsu JR, Mir H, Wally MK, Seymour RB. Clinical practice guidelines for pain management in acute musculoskeletal injury. J Orthop Trauma. 2019;33(5):e158–e82.
Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131–57.
Berry PH, Convington EC, Dahl JL. Pain: current understanding of assessment, management, and treatments. National Pharmaceutical Council, Inc: American Pain Society; 2005.
Campbell KJ, Louie PK, Bohl DD, Edmiston T, Mikhail C, Li J, et al. A novel, automated text-messaging system is effective in patients undergoing total joint arthroplasty. J Bone Joint Surg Am. 2019;101(2):145–51.
Smith DH, Kuntz JL, DeBar LL, Mesa J, Yang X, Schneider J, et al. A randomized, pragmatic, pharmacist-led intervention reduced opioids following orthopedic surgery. Am J Manag Care. 2018;24(11):515–21.
Stanek JJ, Renslow MA, Kalliainen LK. The effect of an educational program on opioid prescription patterns in hand surgery: a quality improvement program. J Hand Surg. 2015;40(2):341–6.
Syed UAM, Aleem AW, Wowkanech C, Weekes D, Freedman M, Tjoumakaris F, 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. J Shoulder Elb Surg. 2018;27(6):962–7.
Collinsworth KM, Goss DL. Battlefield acupuncture and physical therapy versus physical therapy alone after shoulder surgery. Med Acupunct. 2019;31(4):228–38.
Crawford P, Moss DA, Crawford AJ, Sharon DJ. Modified battlefield acupuncture does not reduce pain or improve quality of life in patients with lower extremity surgery. Mil Med. 2019;184(Suppl 1):545–9.
Dasa V, Lensing G, Parsons M, Harris J, Volaufova J, Bliss R. Percutaneous freezing of sensory nerves prior to total knee arthroplasty. Knee. 2016;23(3):523–8.
Fleischman AN, Tarabichi M, Foltz C, Makar G, Hozack WJ, Austin MS, et al. Cluster-randomized trial of opiate-sparing analgesia after discharge from elective hip surgery. J Am Coll Surg. 2019;229(4):335–45.e5.
Tan NLT, Hunt JL, Gwini SM. Does implementation of an enhanced recovery after surgery program for hip replacement improve quality of recovery in an Australian private hospital: a quality improvement study. BMC Anesthesiol. 2018;18(1):64.
Della Valle CJ, Dittle E, Moric M, Sporer SM, Buvanendran A. A prospective randomized trial of mini-incision posterior and two-incision total hip arthroplasty. Clin Orthop Relat Res. 2010;468(12):3348–54.
Verla T, Winnegan L, Mayer R, Cherian J, Yaghi N, Palejwala A, et al. Minimally invasive transforaminal versus direct lateral lumbar interbody fusion: effect on return to work, narcotic use, and quality of life. World Neurosurg. 2018;116:e321–e8.
Walega D, McCormick Z, Manning D, Avram M. Radiofrequency ablation of genicular nerves prior to total knee replacement has no effect on postoperative pain outcomes: a prospective randomized sham-controlled trial with 6-month follow-up. Reg Anesth Pain Med. 2019:rapm-2018-100094. https://doi.org/10.1136/rapm-2018-100094.
Aguirre J, Baulig B, Dora C, Ekatodramis G, Votta-Velis G, Ruland P, et al. Continuous epicapsular ropivacaine 0.3% infusion after minimally invasive hip arthroplasty: a prospective, randomized, double-blinded, placebo-controlled study comparing continuous wound infusion with morphine patient-controlled analgesia. Anesth Analg. 2012;114(2):456–61.
Bhashyam AR, Heng M, Harris MB, Vrahas MS, Weaver MJ. Self-reported marijuana use is associated with increased use of prescription opioids following traumatic musculoskeletal injury. J Bone Joint Surg Am. 2018;100(24):2095–102.
Chevet I, Remérand F, Couvret C, Baud A, Pouplard C, Rosset P, et al. Tranexamic acid reduces haematomas but not pain after total knee arthroplasty. Ann Fr Anesth Reanim. 2011;30(1):17–24.
Fenten MGE, Bakker SMK, Scheffer GJ, Wymenga AB, Stienstra R, Heesterbeek PJC. Femoral nerve catheter vs local infiltration for analgesia in fast track total knee arthroplasty: short-term and long-term outcomes. Br J Anaesth. 2018;121(4):850–8.
Gray P, Kirby J, Smith MT, Cabot PJ, Williams B, Doecke J, et al. Pregabalin in severe burn injury pain: a double-blind, randomised placebo-controlled trial. Pain. 2011;152(6):1279–88.
Hah J, Mackey SC, Schmidt P, McCue R, Humphreys K, Trafton J, et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort: a randomized clinical trial. JAMA Surg. 2018;153(4):303–11.
Hannon CP, Calkins TE, Li J, Culvern C, Darrith B, Nam D, et al. The James A. Rand Young Investigator’s Award: large opioid prescriptions are unnecessary after total joint arthroplasty: a randomized controlled trial. J Arthroplast. 2019;34(7s):S4–s10.
Hyer L, Scott C, Mullen CM, McKenzie LC, Robinson JS. Randomized double-blind placebo trial of duloxetine in perioperative spine patients. J Opioid Manag. 2015;11(2):147–55.
Nader A, Kendall MC, Wixson RL, Chung B, Polakow LM, McCarthy RJ. A randomized trial of epidural analgesia followed by continuous femoral analgesia compared with oral opioid analgesia on short- and long-term functional recovery after total knee replacement. Pain Med. 2012;13(7):937–47.
Schroer WC, Diesfeld PJ, LeMarr AR, Reedy ME. Benefits of prolonged postoperative cyclooxygenase-2 inhibitor administration on total knee arthroplasty recovery: a double-blind, placebo-controlled study. J Arthroplast. 2011;26(6 Suppl):2–7.
Starr JB, Backonja M, Rozet I. Beta-blocker use is associated with a reduction in opioid use 30 days after total knee arthroplasty. Pain Physician. 2019;22(5):E395–406.
Sun EC, Bateman BT, Memtsoudis SG, Neuman MD, Mariano ER, Baker LC. Lack of association between the use of nerve blockade and the risk of postoperative chronic opioid use among patients undergoing Total knee arthroplasty: evidence from the Marketscan database. Anesth Analg. 2017;125(3):999–1007.
Thompson KM, Smith RA, Brolin TJ, Azar FM, Throckmorton TW. Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared with indwelling interscalene catheter in total elbow arthroplasty. J Shoulder Elb Surg. 2018;27(12):2257–61.
Yazdani J, Aghamohamadi D, Amani M, Mesgarzadeh AH, Maghbooli Asl D, Pourlak T. Effect of preoperative oral amantadine on acute and chronic postoperative pain after mandibular fracture surgery. Anesth Pain Med. 2016;6(3):e35900.
Zhuang Q, Tao L, Lin J, Jin J, Qian W, Bian Y, et al. Postoperative intravenous parecoxib sodium followed by oral celecoxib post total knee arthroplasty in osteoarthritis patients (PIPFORCE): a multicentre, double-blind, randomised, placebo-controlled trial. BMJ Open. 2020;10(1):e030501.
Chen EY, Betancourt L, Li L, Trucks E, Marcantonio A, Tornetta P 3rd. Standardized, patient-specific, postoperative opioid prescribing after inpatient orthopaedic surgery. J Am Acad Orthop Surg. 2020;28(7):e304–e18.
Chen Q, Hsia HL, Overman R, Bryan W, Pepin M, Mariano ER, et al. Impact of an opioid safety initiative on patients undergoing total knee arthroplasty: a time series analysis. Anesthesiology. 2019;131(2):369–80.
Choo KJ, Grace TR, Khanna K, Barry J, Hansen EN. A goal-directed quality improvement initiative to reduce opioid prescriptions after orthopaedic procedures. J Am Acad Orthop Surg Glob Res Rev. 2019;3(9):e109.
Earp BE, Silver JA, Mora AN, Blazar PE. Implementing a postoperative opioid-prescribing protocol significantly reduces the total morphine milligram equivalents prescribed. J Bone Joint Surg Am. 2018;100(19):1698–703.
Eley N, Sikora M, Wright AK, Leveque J-C. Implementation of an opioid reduction protocol for simple outpatient neurosurgical procedures: a single-center experience. Spine (Phila Pa 1976). 2020;45(6):397–404.
Holte AJ, Carender CN, Noiseux NO, Otero JE, Brown TS. Restrictive opioid prescribing protocols following total hip arthroplasty and total knee arthroplasty are safe and effective. J Arthroplast. 2019;34(7S):S135–S9.
Joo SS, Hunter OO, Tamboli M, Leng JC, Harrison TK, Kassab K, et al. Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery. Reg Anesth Pain Med. 2020;45(6):474–8.
Padilla JA, Gabor JA, Schwarzkopf R, Davidovitch RI. A novel opioid-sparing pain management protocol following total hip arthroplasty: effects on opioid consumption, pain severity, and patient-reported outcomes. J Arthroplast. 2019;34(11):2669–75.
Reid DBC, Patel SA, Shah KN, Shapiro BH, Ruddell JH, Akelman E, et al. Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion. Spine J. 2019;20(1):69–77.
Reid DBC, Shah KN, Shapiro BH, Ruddell JH, Akelman E, Daniels AH. Mandatory prescription limits and opioid utilization following orthopaedic surgery. J Bone Joint Surg Am. 2019;101(10):e43.
Reid DBC, Shah KN, Shapiro BH, Ruddell JH, Evans AR, Hayda RA, et al. Opioid-limiting legislation associated with reduced postoperative prescribing after surgery for traumatic orthopaedic injuries. J Orthop Trauma. 2020;34(4):e114–e20.
Reid DBC, Shapiro B, Shah KN, Ruddell JH, Cohen EM, Akelman E, et al. Has a prescription-limiting law in Rhode Island helped to reduce opioid use after total joint arthroplasty? Clin Orthop Relat Res. 2019;478(2):205–15.
Tamboli M, Mariano ER, Gustafson KE, Briones BL, Hunter OO, Wang RR, et al. A multidisciplinary patient-specific opioid prescribing and tapering protocol is associated with a decrease in total opioid dose prescribed for six weeks after total hip arthroplasty. Pain Med. 2020;21(7):1474–81.
Vaz KM, Huang PS, Copp SN. Standardized opioid prescription protocol reduces opioid consumption after total joint arthroplasty. J Am Acad Orthop Surg Glob Res Rev. 2019;3(12):e19.00163.
Whale CS, Henningsen JD, Huff S, Schneider AD, Hijji FY, Froehle AW. Effects of the Ohio opioid prescribing guidelines on total joint arthroplasty postsurgical prescribing and refilling behavior of surgeons and patients. J Arthroplast. 2020;35(9):2397–404.
Wyles CC, Hevesi M, Trousdale ER, Ubl DS, Gazelka HM, Habermann EB, et al. The 2018 Chitranjan S. Ranawat, MD Award: developing and implementing a novel institutional guideline strategy reduced postoperative opioid prescribing after TKA and THA. Clin Orthop Relat Res. 2019;477(1):104–13.
Young BT, Zolin SJ, Ferre A, Ho VP, Harvey AR, Beel KT, et al. Effects of Ohio’s opioid prescribing limit for the geriatric minimally injured trauma patient. Am J Surg. 2019;219(3):400–3.
Radi JK. Peri-operative regional nerve blocks (PNB) in the treatment of pain in patients undergoing operative fixation of lower extremity fractures. USA: Western Michigan University; 2017.
Dindo L, Zimmerman MB, Hadlandsmyth K, StMarie B, Embree J, Marchman J, et al. Acceptance and commitment therapy for prevention of chronic postsurgical pain and opioid use in at-risk veterans: a pilot randomized controlled study. J Pain. 2018;19(10):1211–21.
Chambers L, Jaynstein J, Parry JA, Mauffrey C. The effect of the orthopaedic trauma association’s (OTA) pain management guidelines on opioid prescriptions, pain control, and refills in outpatient orthopaedic trauma surgery. Eur J Orthop Surg Traumatol. 2022;32:237–42.
Wyles CC, Hevesi M, Ubl DS, Habermann EB, Gazelka HM, Trousdale RT, et al. Implementation of procedure-specific opioid guidelines: a readily employable strategy to improve consistency and decrease excessive prescribing following orthopaedic surgery. JB JS Open Access. 2020;5(1):e0050.
Cunningham DJ, Paniaugua AR, LaRose MA, DeLaura IF, Blatter MK, Gage MJ. Regional anesthesia does not decrease inpatient or outpatient opioid demand in distal femur fracture surgery. Arch Orthop Trauma Surg. 2021. https://doi.org/10.1007/s00402-021-03892-2.
Cunningham DJ, Robinette JP, Paniagua AR, LaRose MA, Blatter M, Gage MJ. Regional anesthesia does not decrease opioid demand in pelvis and acetabulum fracture surgery. Eur J Orthop Surg Traumatol. 2021. https://doi.org/10.1007/s00590-021-03114.104.
Bérubé M, Dupuis S, Leduc S, Roy I, Côté C, Grzelak S, et al. Tapering opioid prescription program for high-risk trauma patients: a pilot randomized controlled trial. Pain Manag Nurs. 2021. https://doi.org/10.1016/j.pmn.2021.08.001.
Singer KE, Philpott CD, Bercz AP, Phillips T, Salyer CE, Hanseman D, et al. Impact of a multimodal analgesia protocol on inpatient and outpatient opioid use in acute trauma. J Surg Res. 2021;268:9–16.
Chalmers BP, Lebowitz J, Chiu YF, Joseph AD, Padgett DE, Bostrom MPG, et al. Changes in opioid discharge prescriptions after primary total hip and total knee arthroplasty affect opioid refill rates and morphine milligram equivalents: an institutional experience of 20,000 patients. Bone Joint J. 2021;103-b(7 Supple B):103–10.
Cunningham DJ, George SZ, Lewis BD. The impact of state level public policy, prescriber education, and patient factors on opioid prescribing in elective orthopedic surgery: findings from a tertiary, academic setting. Mayo Clin Proc Innov Qual Outcomes. 2021;5(1):23–34.
Raji Y, Strony JT, Trivedi NN, Kroneberger E, Yu J, Calcei JG, et al. Effects of opioid-limiting legislation on postoperative opioid use in shoulder arthroplasty in an epidemic epicenter. J Shoulder Elb Surg. 2022;31:269-75.
Sabesan VJ, Echeverry N, Dalton C, Grunhut J, Lavin A, Chatha K. The impact of state-mandated opioid prescribing restrictions on prescribing patterns surrounding reverse total shoulder arthroplasty. JSES Int. 2021;5(4):663–6.
Burns KA, Robbins LM, LeMarr AR, Childress AL, Morton DJ, Schroer WC, et al. Celecoxib significantly reduces opioid use after shoulder arthroplasty. J Shoulder Elb Surg. 2021;30(1):1–8.
Cheesman Q, DeFrance M, Stenson J, Weekes D, Feldman J, Abboud 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. J Shoulder Elb Surg. 2020;29(9):1743–50.
Urban JA, Dolesh K, Martin E. A multimodal pain management protocol including preoperative cryoneurolysis for total knee arthroplasty to reduce pain, opioid consumption, and length of stay. Arthroplast Today. 2021;10:87–92.
Buys MJ, Bayless K, Romesser J, Anderson Z, Patel S, Zhang C, et al. Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service. Reg Anesth Pain Med. 2020;45(11):847–52.
Li WT, Bell KL, Yayac M, Barmann JA, Star AM, Austin MS. A postdischarge multimodal pain management cocktail following total knee arthroplasty reduces opioid consumption in the 30-day postoperative period: a group-randomized trial. J Arthroplast. 2021;36(1):164–72.e2.
Bovonratwet P, Chen AZ, Shen TS, Ondeck NT, Kunze KN, Su EP. Postoperative patient-reported pain and opioid consumption after total hip arthroplasty: a comparison of the direct anterior and posterior approaches. J Am Acad Orthop Surg. 2022;30:e108–17.
Varady NH, Smith EL, Clarkson SJ, Niu R, Freccero DM, Chen AF. Opioid use following inpatient versus outpatient total joint arthroplasty. J Bone Joint Surg Am. 2021;103(6):497–505.
Hanley AW, Gililland J, Garland EL. To be mindful of the breath or pain: comparing two brief preoperative mindfulness techniques for total joint arthroplasty patients. J Consult Clin Psychol. 2021;89(7):590–600.
Hah JM, Trafton JA, Narasimhan B, Krishnamurthy P, Hilmoe H, Sharifzadeh Y, et al. Efficacy of motivational-interviewing and guided opioid tapering support for patients undergoing orthopedic surgery (MI-Opioid Taper): a prospective, assessor-blind, randomized controlled pilot trial. EClinicalMedicine. 2020;28:100596.
Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, Mythen M, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 joint consensus statement on persistent postoperative opioid use: definition, incidence, risk factors, and health care system initiatives. Anesth Analg. 2019;129(2):543–52.
Clarke HA, Manoo V, Pearsall EA, Goel A, Feinberg A, Weinrib A, et al. Consensus statement for the prescription of pain medication at discharge after elective adult surgery. Can J Pain. 2020;4(1):67–85.
Edwards DA, Hedrick TL, Jayaram J, Argoff C, Gulur P, Holubar SD, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus statement on perioperative management of patients on preoperative opioid therapy. Anesth Analg. 2019;129(2):553–66.
Soffin EM, Waldman SA, Stack RJ, Liguori GA. An evidence-based approach to the prescription opioid epidemic in orthopedic surgery. Anesth Analg. 2017;125(5):1704–13.
Mai J, Franklin G, Tauben D. Guideline for prescribing opioids to treat pain in injured workers. Phys Med Rehabil Clin N Am. 2015;26(3):453–65.
Washington State Agency Medical Directors’ Group. Interagency guideline on prescribing opioids for pain. 3rd ed. Washington: Washington State Agency Medical Directors’ Group; 2015.
U.S. Department of Health and Human Services. Pain management best practices inter-agency task force report: updates, gaps, inconsistencies, and recommendations. 2019.
Galvagno SM Jr, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, et al. Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936–51.
Wu CL, King AB, Geiger TM, Grant MC, Grocott MPW, Gupta R, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on perioperative opioid minimization in opioid-naïve patients. Anesth Analg. 2019;129(2):567–77.
Ftouh S, Morga A, Swift C. Management of hip fracture in adults: summary of NICE guidance. BMJ. 2011;342:d3304.
Fischer HB, Simanski CJ, Sharp C, Bonnet F, Camu F, Neugebauer EA, et al. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia. 2008;63(10):1105–23.
The committee on trauma of the American College of Surgeons. ACS Trauma Quality Programs. Best practices guidelines for acute pain management in trauma patients. Chicago: The committee on trauma of the American College of Surgeons; 2020.
Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, et al. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021;76(8):1082–97.
Fillingham YA, Hannon CP, Erens GA, Hamilton WG, Della Valle CJ. Acetaminophen in total joint arthroplasty: the clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplast. 2020;35(10):2697–9.
Franz S, Schulz B, Wang H, Gottschalk S, Grüter F, Friedrich J, et al. Management of pain in individuals with spinal cord injury: guideline of the German-Speaking Medical Society for Spinal Cord Injury. Ger Med Sci. 2019;17:Doc05.
Sodhi N, Mont MA. Consensus on reducing risk in total joint arthroplasty: narcotic use. Tech Orthop. 2019;34(3):187–92.
Trexler LE, Corrigan JD, Davé S, Hammond FM. Recommendations for prescribing opioids for people with traumatic brain injury. Arch Phys Med Rehabil. 2020;101(11):2033–40.
Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. Acta Orthop. 2020;91(1):3–19.
Buys MJ, Bayless K, Romesser J, Anderson Z, Patel S, Zhang C, et al. Multidisciplinary transitional pain service for the veteran population. Fed Pract. 2020;37(10):472–8.
Anthony CA, Rojas EO, Keffala V, Glass NA, Shah AS, Miller BJ, et al. Acceptance and commitment therapy delivered via a mobile phone messaging robot to decrease postoperative opioid use in patients with orthopedic trauma: randomized controlled trial. J Med Internet Res. 2020;22(7):e17750.
Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7:50.
Dave CV, Patorno E, Franklin JM, Huybrechts K, Sarpatwari A, Kesselheim AS, et al. Impact of state laws restricting opioid duration on characteristics of new opioid prescriptions. J Gen Intern Med. 2019;34(11):2339–41.
Davis CS, Piper BJ, Gertner AK, Rotter JS. Opioid prescribing laws are not associated with short-term declines in prescription opioid distribution. Pain Med. 2020;21(3):532–7.
Sacks DW, Hollingsworth A, Nguyen TD, Simon KI. Can policy affect initiation of addictive substance use ? Evidence from opioid prescribing. Massachusetts; 2019. Available from: https://www.nber.org/papers/w25974.pdf
Chua KP, Kimmel L, Brummett CM. Disappointing early results from opioid prescribing limits for acute pain. JAMA Surg. 2020;155(5):375–6.
Heimer R, Hawk K, Vermund SH. Prevalent misconceptions about opioid use disorders in the United States produce failed policy and public health responses. Clin Infect Dis. 2019;69(3):546–51.
Liang D, Wallace MS, Shi Y. Medical and non-medical cannabis use and risk of prescription opioid use disorder: findings from propensity score matching. Drug Alcohol Rev. 2019;38(6):597–605.
DiBenedetto DJ, Weed VF, Wawrzyniak KM, Finkelman M, Paolini J, Schatman ME, et al. The association between Cannabis use and aberrant behaviors during chronic opioid therapy for chronic pain. Pain Med. 2018;19(10):1997–2008.
Marquez-Lara A, Hutchinson ID, Nuñez F Jr, Smith TL, Miller AN. Nonsteroidal anti-inflammatory drugs and bone-healing: a systematic review of research quality. JBJS Rev. 2016;4(3):e4.
Curiel RV, Katz JD. Mitigating the cardiovascular and renal effects of NSAIDs. Pain Med. 2013;14(Suppl 1):S23–8.
Zhao-Fleming H, Hand A, Zhang K, Polak R, Northcut A, Jacob D, et al. Effect of non-steroidal anti-inflammatory drugs on post-surgical complications against the backdrop of the opioid crisis. Burns Trauma. 2018;6:25.
Wheatley BM, Nappo KE, Christensen DL, Holman AM, Brooks DI, Potter BK. Effect of NSAIDs on bone healing rates: a meta-analysis. J Am Acad Orthop Surg. 2019;27(7):e330–e6.
Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions aimed at reducing use of low-value health services: a systematic review. Med Care Res Rev. 2017;74(5):507–50.
Marin TJ, Van Eerd D, Irvin E, Couban R, Koes BW, Malmivaara A, et al. Multidisciplinary biopsychosocial rehabilitation for subacute low back pain. Cochrane Database Syst Rev. 2017;6(6):Cd002193.
Sutton DA, Côté P, Wong JJ, Varatharajan S, Randhawa KA, Yu H, et al. Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J. 2016;16(12):1541–65.
Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014;160(1):38–47.
Voon P, Karamouzian M, Kerr T. Chronic pain and opioid misuse: a review of reviews. Subst Abuse Treat Prev Policy. 2017;12:1–9.
Frank JW, Lovejoy TI, Becker WC, Morasco BJ, Koenig CJ, Hoffecker L, et al. Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. Ann Intern Med. 2017;167(3):181–91.
Ministère de la santé et des services sociaux. Quebec trauma registry (2012-2016). Québec: Ministère de la santé et des services sociaux; 2019.
Compton WM, Jones CM. Epidemiology of the U.S. opioid crisis: the importance of the vector. Ann N Y Acad Sci. 2019;1451(1):130–43.
Bartley EJ, Fillingim RB. Sex differences in pain: a brief review of clinical and experimental findings. Br J Anaesth. 2013;111(1):52–8.
Samulowitz A, Gremyr I, Eriksson E, Hensing G. “Brave men” and “emotional women”: a theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Res Manag. 2018;2018:6358624.
We thank Oussama Salmane for his support in the selection of studies and data extraction. We are also grateful to Marc-Aurèle Gagnon for his participation in the edition of tables.
This study was funded by the Quebec Pain Research Network (QPRN). Dr. Bérubé is the recipient of salary support awards from the Fond de Recherche du Québec – Santé (FRQS) and the Strategy for Patient-Oriented Research (SPOR)-Québec. Dr. Moore and Dr. Lauzier, Dr. Pagé, Dr. Perreault and Dr. Sirois are recipients of salary support awards from the FRQS. Dr. Martel is the Chairholder of the Canada Research Chair in Chronic Pain, Mental Health and Opioid Use. Dr. Turgeon is the Chairholder of the Canada Research Chair in Critical Neurology and Trauma. Funding bodies had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.