Table 1 Study characteristics, description of strategies and outcomes

  Chambers 2021

USA [96]

Prospective cohort

86

37

40%

Outpatient orthopaedic trauma surgery

Implementation of the Orthopaedic Trauma Association (OTA) pain management guidelines for acute musculoskeletal injuries

Before guidelines implementation

Cumulative MED

6 weeks:

I; 210.00; C: 225.00,

95% CI -85.00 - 20.00, p = 0.10

Proportion of patients who received opioid refill(s)

I: 2.00%; C: 2.00%,

95% CI -9.00 - 8.00, p = 1.00

Proportion of patients using opioids (adherent vs non-adherent to guidelines for discharge prescription)

6 weeks:

Adherent: 17.00%;

Non-adherent: 13.00%

95% CI − 22.00 - 13.00

p = 0.70

  Chen 2020

USA [77]

Prospective cohort

2,940

57

53%

Orthopaedic surgery including for traumatic fractures

A patient-specific protocol using an opioid taper calculator to standardize opioid prescribing at discharge after inpatient orthopaedic surgery

Before protocol implementation

MED

At discharge:

I: 326.00; C: 427.00,

p < 0.001

Refills

mean

1 month:

I: 1.71; C: 1.58, p = 0.08

  Reid 2020

USA [87]

Retrospective cohort

753

57

56%

Orthopaedic trauma

State of Rhode Island legislation on strict opioid prescription limits. These limits prohibited providers from prescribing more than 30 MED per day, 150 total MED, or 20 total doses initially following a surgical procedure.

Idem as Reid 2019

Cumulative MED

1 month:

I: 481.70; C: 677.40, p < 0.001

Opioid-tolerant:

I: 880.00; C: 1,659.20, p = 0.04

Opioid-naïve:

I: 478.10; C: 633.70, p < 0.001

30-90 days:

I: 265.10; C: 256.70, p = 0.83

Opioid-tolerant:

I: 923.80; C: 1,691.10, p = 0.10

Opioid-naïve:

I: 241.10; C: 206.90, p = 0.90

  Wyles 2020

USA [97]

Retrospective

4,523

63

51%

Orthopaedic and spine surgery including for traumatic fractures

Implementation of procedure-specific guidelines for discharge opioid prescriptions

Before guidelines implementation

MED

AT discharge:

I: 375.00; C: 600.00

p < 0.001

Proportion of patients who received opioid refill(s)

1 month:

I: 24.00%; C: 25.00%

p = 0.43

  Choo 2019

USA [79]

Retrospective cohort

830

63

48%

Orthopaedic surgery including for traumatic fractures

A quality improvement project using report sent to health professionals every two months, which showed median discharge MED per patient and reinforcement on multimodal pain management strategies

Before quality improvement project implementation

MED

At discharge:

I: 450.00; C: 600.00,

p < 0.001

Proportion of patients who received opioid refill(s)

Between discharge to 1 month:

I: 24.00%; C: 25.70%, p = 0.58

Between 1 to 2 months:

I: 14.90%; C: 14.20%, p = 0.77

Between 2 to 3 months:

I: 7.80%; C: 6.50%, p = 0.58

  Reid 2019

USA [86]

Retrospective cohort

1,776

55

55%

Orthopaedic surgery including for traumatic fractures

Idem as Reid 2019

Before legislation implementation

Cumulative MED

1 month:

I: 524.50; C: 790.00, p < 0.001

Opioid-Tolerant:

I: 1,015.20; C: 1,304.10,

p = 0.001

Opioid-Naïve:

I: 446.57; C: 708.84,

p < 0.001

Between 1 to 3 months:

I: 208.50; C: 243.50, p = 0.007

Opioid-Tolerant:

I: 804.60; C: 892.60, p = 0.08

Opioid-Naïve:

I: 113.70; C: 141.00, p = 0.02

Proportion of patients using opioids

At 30 days:

I: 24.00%; C: 28.00%, p = 0.03

  Young 2019

USA [93]

Retrospective cohort

218

75

72%

Minor non-surgical trauma

After Ohio's opioid prescription limit (opioids for 7 days and a total of 210 MEDs)

Before opioid prescription limit

Cumulative MED

1 month:

I: 105.00; C: 375.00, p = 0.02

  Earp 2018

USA [80]

Retrospective cohort

518

54

61%

Hand and upper-extremity surgeries including for traumatic fractures

Postoperative opioid-limit prescribing protocol

Before protocol implementation

MED

At discharge

Tier^b 1:

I: 39.20; C: 113.60, p < 0.001

Tier 2:

I: 61.40; C: 171.10, p < 0.001

Tier 3:

I: 131.20; C: 229.60, p < 0.001

Tier 4:

I: 208.10; C: 264.80, p < 0.02

Tier 5:

I: 246.90; C: 369.90, p < 0.003

MED decreased by a minimum of 97.80% and a maximum of 176.00% (p < 0.05 for all tiers)

Proportion of patients who received opioid refill

1 refill:

I: 1.70%; C: 6.50%, p < 0.001

2 refills:

I: 0.00%; C: 1.70%, p < 0.001

  Cunningham 2021

USA [98]

Retrospective cohort

230

64

65%

Distal femur fracture surgery

Regional anesthesia

Without regional anesthesia

Cumulative MED

6 weeks:

I: 95.10; C:74.90

Incident rate ratio : 1.27, 95% CI 1.01-1.59,

p = 0.03

3 months:

I: 112.10; C:85.00

Incident rate ratio : 1.33, 95% CI (1.07, 1.66),

p = 0.01

Between 6 weeks to 3 months:

I : OR 1.85 95% IC (1.14, 3.04)

p = 0.014

  Cunningham 2021

USA [99]

Retrospective

230

41

35%

Pelvis and acetabulum fracture surgery

Regional anesthesia

Without regional anesthesia

Cumulative MED

6 weeks:

I: 177.20; C:145.20

Incident rate ratio : 1.22, 95% CI 0.99-1.51,

p = 0.06

3-months:

I: 207.90; C:156.80

Incident rate ratio 1.33,

95% CI 1.06-1.65, p = 0.01

Opioid fill

Between 6 weeks to 3 months:

I : OR 2.05, 95% CI 1.24- 3.46, p = 0.006

  Bhashyam 2018

USA [63]

Prospective cohort

500

50

50%

Orthopaedic trauma

Recreational use or self-medication with marijuana

I1: Prior user

I2: Use during recovery

Never use marijuana

Total prescribed MED

6 months:

Marijuana used during recovery compared to never users (mean difference = 343.00, p = 0.03)

Duration of opioid use (days)

Marijuana used during recovery compared to never users (mean difference = 12.50, p = 0.03)

Proportion of patients using opioids (%)

Persistent Use for > 3 months :

I1: 25.90%; I2: 21.70%; C: 17.60%, no significance test

  Radi 2017

USA [94]

Retrospective cohort

216

NS

37%

Orthopaedic trauma

Peri-operative regional nerve block (single shot)

No block

Proportion of patients using opioids

3 months:

I: 44.20%; C: 34.80%, p = 0.22

6 months:

I: 7.70%; C: 14.60%, p = 0.19

  Yazdani 2016

Iran [75]

Randomized controlled trial

60

32

17%

Trauma: ORIF of a recent mandibular unilateral body fracture

A 100 mg dose of Amantadine one hour before surgery

Placebo capsule

Cumulative MED

6 months:

I: 121.70; C: 106.00, p = 0.61

  Gray 2011

Australia [66]

Randomized controlled trial

90

36

17%

Burn injury

Pregabalin (75 mg to 300 mg titration according to pain level) twice daily for 28 days and weaned and ceased over the next 6 days.

Placebo capsules

Morphine Parenteral Equivalent/ day

1 month:

I: 14.92; C: 14.92, p = 0.09

  Bérubé 2021

Canada [100]

Randomized controlled trial

49

41

25%

Traumatic injury requiring hospital- ization. Patients receiving > 2 doses/ day of opioid at discharge and with at least one risk factor for chronic opioid use

TOPP-Trauma programme + UC. This educational program (2 x 10 min session prior discharge and max 6 x 15 min opioid tapering counselling session every 2 weeks after discharge) focused on multimodal pain management strategies and guidance about opioid tapering

UC + an educational pamphlet received before discharge

Reported MED/day

6 weeks:

I: 1.20; C: 12.20,

95% CI –22.00-0.10

3 months :

I: 0.40; C: 4.10,

95% CI – 8.30-0.70

Total MED delivered

6 weeks:

I: 618.19; C: 1,009.00,

95% CI –1,324.00-542.10

3 months :

I: 679.00; C: 1,443.40,

95% CI – 1,781.60-248.60

Proportion of patients using opioids (%)

6 weeks:

I: 17.00%; C: 29.00%,

p > 0.05

3 months:

I: 12.00%; C: 16.00%,

p > 0.05

  Syed 2018

USA [53]

Randomized controlled trial

134

59

32%

Arthroscopic rotator cuff repair

Formal education detailing recommended postoperative opioid usage, side effects, dependence, and addiction

Preoperative education regarding surgery

Cumulative MED

6 weeks:

I: 40.40; C: 60.60, p = 0.02

3 months:

I: 51.20; C: 87.20, p = 0.01

Opioids discontinua-tion

Between 6 weeks to 3 months:

OR: 2.19, 95% CI 1.10-4.39, p = 0.03

  Stanek 2015

USA [52]

Retrospective cohort

NS

NS

NS

Hand surgery including for traumatic fractures

Implementation of an educational assist device to serve as a memory prompt of narcotic guidelines

Before implementation of the educational assist device

Reduction in opioid prescription (%)

3 months:

Repair of a metacarpal fracture: 20.00% reduction, p = 0.04

  Holman 2014

USA [5]

Retrospective cohort

613

43

38%

Orthopaedic trauma

A standardized discussion with patients aiming to inform them that they would receive opioids for a maximum of 6 weeks postoperatively

No standardized discussion but limited postoperative opioids prescriptions to 12 weeks

Proportion of patients using opioids

6 weeks:

I: 27.00%; C: 36.00%, p = 0.01

3 months:

I: 20.00%; C: 20.00%, p = 0.90

  Singer 2021

USA [101]

Retrospective cohort

620

49

32%

Hospitalized trauma patients

Multimodal analgesia protocol and corresponding electronic medical record order set (including opioids, NSAID and gabapentin who were adjusted for age and medical condition)

Before implementation of multimodal protocol.

Cumulative outpatient MED

6 months:

I: 210.00; C: 263.00,

p = 0.03

Proportion of patients using opioids chronically

(opioid prescription at 6 mo)

I: 3.20%; C:3.10%,

p = 0.62

  Crawford 2019

USA [55]

Randomized controlled trial

233

45

39%

Lower extremity surgery including for traumatic injuries

(military population)

Standard care and modified battlefield acupuncture with semi-permanent needles

C1: standard care + small adhesive bandages on the ear

C2: standard care + placebo auricular acupuncture with semi-permanent needles

Cumulative MED

1 month:

I: 257.00; C1: 358.00;

C2: 266.00, p = 0.22

  Chalmers 2021

USA [102]

Retrospective cohort

19428

63

53%

THA or TKA

Modification of routine discharge MED (C = 750 MED, I1 = 520 MED, I2 = 320 MED)

Before routine discharge reduction (C)

Cumulative MED (mean)

3 months

Total population:

I1: 798.00; I2: 556.00; C: 1,009.00, p < 0.001

Postoperative refill in MED (mean)

Total population:

I1: 859.00; I2: 682.00; C: 1,017.00, p < 0.001

Proportion of patients who received opioid refill(s)

Total population:

I1: 33.00%; I2: 33.00%; C: 28.00%,

p < 0.001

  Cunningham 2021

USA [103]

Retrospective cohort

4,592

61

57%

ACDF, ACLR, CTR, RCR, TAA, THA, TKA, trapeziec-tomy with suspension-plasty

North Carolina legislation. The STOP Act requires to review a patient’s 12-month history before issuing an initial prescription for an opioid and instituting a 5-day limit on initial prescriptions for acute pain and a 7-day limit on postoperative prescriptions + institutional educational materials for practitioners and patients about responsible opioid prescribing, opioid use, and North Carolina law (I1: immediately after implementation; I2: 1 year after implementation)

Before implementation of the STOP Act legislation and departmental policies (C)

Total MED prescribed

6 weeks:

I1:126.15; I2: 120.30; C: 184.95,

p < 0.001

Proportion of patients who received more than one prescription

I1: 30.50%; I2: 31.70%;

C: 37.20%, p < 0.001

  Raji 2021

USA [104]

Retrospective case-control

334

69

65%

Different types of shoulder arthroplasty

After Ohio legislation which limit opioid prescriptions to no more than 7 days at a time for adults, with a maximum allotted dose per day of 30 morphine milligram equivalents

Before implementation of Ohio legislation

Total MED

1 month:

Total:

I: 300.00; C: 570.00,

p < 0.001

Opioid tolerant:

I: 740.00; C: 825.00,

p = 0.551

Oioid naïve:

I: 210.00; C: 450.00,

p < 0.001

Between 1 to 2 months:

Total:

I: 0.00; C: 0.00,

p = 0.88

Opioid tolerant:

I: 360.00; C: 300.00,

p = 0.449

Oioid naïve:

I: 0.00; C: 0.00,

p = 0.779

Between 2 to 3 months:

Total:

I: 0.00; C: 0.00,

p = 0.47

Opioid tolerant:

I: 405.00; C: 300.00,

p = 0.506

Oioid naïve:

I: 0.00; C: 0.00,

p = 0.853

Between discharge to 3 months:

Total:

I: 450.00; C: 600.00,

p < 0.001

Opioid tolerant:

I: 1,680.00; C: 1,455.00,

p = 0.802

Oioid naïve:

I: 210.00; C: 487.50,

p < 0.001

  Sabesan 2021

USA [105]

Retrospective cohort

143

73

56%

Primary reverse shoulder arthroplasty

After Florida House bill 21 law (restriction of 3 to 7-days supply of opiates for acute pain)

Before House Bill 21 law.

Cumulative MED

3 months:

I: 461.90; 1750.7,

p = 0.035

Proportion of patients who received opioid refill(s)

I: 17.80%; C: 70.1%,

p < 0.001

Proportion of patients using opioids chronically

(for 3 or more months of continuous usage)

I: 12.50%; C: 23.00%,

p < 0.043

  Eley 2020

USA [81]

Retrospective cohort

246

59

38%

Spine surgery

Implementation of an opioid prescription-limit protocol

Before protocol

implementation

MED

At discharge:

I: 120.60; C: 286.90,

p < 0.001

Proportion of patients who received opioid refill

3 months:

I: 17.10%; C: 16.50%, p = 0.98

Proportion of patients transitioning to chronic opioid use

I: 2.40%; C: 4.60%, p = 0.70

  Joo 2020

USA [83]

Retrospective cohort

83

67

1%

Spine surgery

An individualized discharge opioid prescribing and tapering protocol

Before protocol implementation

Cumulative MED (median)

Proportion of patients who received opioid refill(s)

6 months:

I:300.00; C:900.00, p < 0.01

I: 36.80%; C: 40.00%, p = 0.77

  Tamboli 2020

USA [89]

Retrospective cohort

49

68

8%

THA

Multidisciplinary patient-specific opioid prescribing and tapering protocol

Before protocol implementation

Cumulative MED (median)

6 weeks:

I: 295.00; C: 900.00

MD: 721, 95% CI 127.00-1,316.00, p = 0.007

Proportion of patients who received opioid refill

I: 54.00%; C: 48.00%, p = 0.67

> 1 refill:

I: 54.00%; C: 67.00%, p = 0.69

  Whale 2020

USA [91]

Retrospective cohort

1,994

68

62%

THA or TKA

After Ohio Opioid Prescribing Guidelines

Before implementation of prescribing guidelines

Cumulative MED

Total (acute and chronic follow-ups):

TKA cohort:

All: I: 1,145.80; C: 1,602.60, p < 0.01

THA cohort:

All: I: 878.30; C: 1,302.30, p < 0.01

Between discharge to < 3 months (acute)

TKA cohort:

I: 390.70; C: 519.70, p = 0.02

THA cohort:

I: 178.60; C: 232.10, p = 0.27

≥ 3 month (chronic)

TKA cohort: All:

I: 148.80; C: 178.10, p = 0.48

THA cohort:

All: I: 69.00; C: 121.80,

p = 0 .12

Proportion of patients who received opioid refill(s)

Acute:

TKA:

I: 47.20%; C: 41.50%, p = 0.50

THA:

I: 25.70%; C: 18.30%, p = 0.01

Chronic:

TKA:

I: 12.00%; C: 12.70%, p = 0.72

THA:

I: 9.50%; C: 10.00%, p = 0.83

  Chen 2019

USA [78]

Retrospective cohort

60,056

65

7%

TKA (veteran population)

Opioid safety initiative that combined education, guideline dissemination with audit and feedback using dashboards

Before opioid safety initiative implementation

Proportion of patients using opioids chronically

(for greater than 3 months in a 6-month period)

6 months:

Post-operative chronic user:

I: 14.10%; C: 26.90%,

p < 0.001

  Holte 2019

USA [82]

Retrospective cohort

399

61

52%

TKA and THA

Implementation of strict postoperative opioid prescription guidelines and mandatory preoperative patient education session led by nursing staff regarding postoperative pain management with an emphasis on opioid use

Before implementation of guidelines

MED

At discharge:

I: 387.30; C: 751.50

p < 0.0001

Total postoperative refill in MED

3 months:

I: 84.00; C: 253.00, p = 0.004

Number of refills (mean)

I: 0.30; C: 0.50, p = 0.02

Number of call-ins pertaining to pain management (mean)

I: 0.40; C: 0.70, p = 0.03

  Reid 2019

USA [88]

Retrospective cohort

1,125

67

62%

THA or TKA

State of Rhode Island legislation on strict opioid prescription limits. These limits prohibited providers from prescribing more than 30 MED per day, 150 total MED, or 20 total doses initially following a surgical procedure.

Before legislation implementation

Cumulative MED

1 month:

I: 632.00; C: 907.00, p < 0.001

Opioid-Tolerant:

I: 1,288.00; C: 1,398.00, p = 0.06

Opioid-Naïve:

I: 501.00; C: 796.00, p < 0.001

1to 3 months:

I: 270.00; C: 279.00, p = 0.19

Opioid-Tolerant:

I: 1,119.00; C: 898.00, p = 0.96

Opioid-Naïve:

I: 100.00; C: 139.00, p = 0.17

Number of refills

1 month:

I: 2.20; C:1.90, p < 0.001

Opioid-Tolerant:

I: 3.0; C: 2.50, p = 0.03

Opioid-Naïve:

I: 2.10; C: 1.80, p < 0.001

  Reid 2019

USA [85]

Retrospective cohort

211

52

54%

Spine Surgery

Idem

Idem

Number of prescriptions (n)

1 month:

I: 1.70; C:1.60, p = 0.42

Cumulative MED

1 month:

I: 444.10; C: 877.90, p < 0.001

Opioid-Tolerant:

I: 632.20; C: 1,122.90, p < 0.001

Opioid-Naïve:

I: 363.40; C: 730.10, p < 0.001

Between 1 to 2 months:

I: 129.50; C: 181.00, p = 0.25

Opioid-Tolerant:

I: 407.90; C: 546.20, p = 0.23

Opioid-Naïve:

I: 150.30; C: 207.00, p = 0.13

61 to 90 days:

I: 91.90; C: 153.60, p = 0.19

Opioid-Tolerant:

I: 226.70; C: 272.20, p = 0.82

Opioid-Naïve:

I: 87.90; C: 126.10, p = 0.30

91 to 120 days:

I: 131.20; C: 136.80, p = 0.08

Opioid-Tolerant:

I: 181.20; C: 274.00, p = 0.21

Opioid-Naïve:

I: 53.70; C: 81.00, p = 0.07

  Vaz 2019

USA [90]

Prospective cohort

196

68

58%

THA or TKA

Standardized opioid prescription protocol: maximum of 30 pills (370 MED) for THA and 40 pills (490 MED) for TKA

Postoperative analgesic prescription at provider’s discretion

Cumulative MED

1 month:

TKA cohort:

I: 200.00; C: 504.00, p < 0.001

THA cohort:

I: 432.00; C: 902.00, p < 0.001

Proportion of patients who received opioid refill(s)

TKA cohort:

I: 50.00%; C: 29.00%, p = 0.04

THA Cohort:

I: 16.00%; C: 8.00%, p = 0.2

  Wyles 2019

USA [92]

Retrospective cohort

2573

67

53%

TKA or THA

Clinicians were recommended to prescribe a maximum MED for an opioid prescription based on the procedure level: Level 1 = 100 MED, Level 2 = 200 MED, Level 3 = 300 MED, and Level 4= 400 MED

Prescriptions without guidelines

Cumulative MED (median)

1 month (median):

TKA cohort:

I: 388.00; C: 750.00, p < 0.001

THA cohort:

I: 388.00; C: 750.00, p < 0.001

Proportion of patients who received opioid refill(s)

TKA cohort:

I: 35.00%; C: 35.00%, p = 0.77

THA cohort:

I: 17.00%; C: 16.00%, p = 0.55

  Burns 2021 USA [106]

Randomized controlled trial

157

61

52%

Scheduled shoulder arthroplasty (group 1)

or ARCR (group 2)

Celecoxib 200 mg twice daily for 3 weeks

Placebo medication

Difference in MED between I and C group (ß)

6 weeks:

Total population:

–198.80 p = 0.01

Group 1

–270.00 p = 0.04

Group 2:

–94.50 p = 0.31

  Zhuang 2020

China [76]

Randomized controlled trial

246

68

80%

TKA

Supplied sequential treatment with intravenous parecoxib 40 mg (every 12 hours) for the first 3 days after surgery, followed by oral celecoxib 200 mg (every 12 hours) for up to 6 weeks

Placebo medication

Cumulative MED (median)

1 month:

I: 53.33; C: 166.50

Median difference: 112.02, 95% CI 43.12-150.92, p < 0.001

6 months:

I: 58.00; C: 180.35

Median difference: 120.92, 95% CI 57.34-181.81, p < 0.001

  Starr 2019

USA [72]

Randomized controlled trial

11,614

66

6%

TKA

(veteran population)

β-blocker within 90 days prior to surgery, β-blocker as an inpatient on postoperative day 0 or 1, and refill prescription for a β-blocker within 90 days after surgery

No β-blocker

Cumulative MED

1 month:

I: 86.10; C: 90.40, p = 0.004

Proportion of patients using opioids

1 month:

OR 0.89, 95% CI 0.80-0.99, p = 0.02

3 months:

OR 1.00, 95% CI 0.87-1.15, p = 0.965

12 months:

OR 1.04, 95% CI 0.90-1.20, p = 0.54

  Fenten 2018

Netherlands [65]

Randomized controlled trial

153

65

54%

TKA

LIA of the posterior capsule and a FNB catheter

Periarticular LIA with ropivacaine 0.2% for postoperative analgesia

Proportion of patients using opioids

3 months:

I: 7.90%; C: 13.00%

No significance test

12 months:

I: 5.40%; C: 2.60%

No significance test

  Hah 2018

USA [67]

Randomized controlled trial

410

57

58%

Surgeries: orthopeadic (80% of patients), thoracotomy, and breast

Four capsules of gabapentin, 300mg preoperatively and two capsules of gabapentin, 300 mg, 3 times a day postoperatively (10 total doses)

Placebo capsules

Proportion of patients using opioids

6 months:

I: 2.40%; C: 2.00%

OR 1.22, 95% CI 0.32-4.66, p = 0.80

12 months:

I: 1.90%; C: 1.50%

OR 1.28, 95% CI 0.28-5.87, p = 0.70

  Thompson 2018

USA [74]

Retrospective cohort

44

70

68%

TEA

Liposomal bupivacaine mixture through indwelling interscalene catheter

Indwelling interscalene catheter

Cumulative MED

3 months:

I: 1,198.60; C: 1,762.50,

p = 0.19

  Sun 2017

USA [73]

Retrospective cohort

120,080

57

61%

TKA

Nerve Block

No nerve block

Proportion of patients using opioids chronically

(having filled 10 or more prescriptions or >120 days’ supply within the first year of surgery, excluding the first 90 postoperative days)

12 months:

Opioid naïve:

I: 1.78%; C: 1.81%, p = 0.744

Adjusted for patient demographics, comorbidities, and preoperative medication use (ARR): 0.98, 98.3% CI 0.847-1.14, p = 0.79

Chronic user:

I: 67.60%; C: 67.80%,

p = 0.761

Intermittent user:

I: 6.08%; C: 6.15%, p = 0.787

  Hyer 2015

USA [69]

Randomized controlled trial

70

53

48%

Spinal surgery

Duloxetine once a day 2 weeks before and more then 3 months after surgery

Placebo capsule

Opioid use

1 month:

p > 0.05

  Aguirre 2012

Switzerland [62]

Randomized controlled trial

72

58

51%

Minimally invasive hip surgery

20 mL ropivacaine 0.3% applied into the wound as a bolus before wound closure followed with a continuous infusion of ropivacaine 0.3% at 8 mL/h for 48 hours after surgery

NaCl 0.9% placebo

Opioid use

  Nader 2012

USA [70]

Randomized controlled trial

62

65

70%

TKA

Continuous femoral analgesia for 24 hours

Oral opioid analgesia

Median daily MED

1 month:

I: 10.00 mg; C: 18.00 mg, p = 0.12

6 months:

I: 0.00; C: 0.00, p = 0.63

  Chevet 2011

France [64]

Prospective cohort

107

72

72%

TKA

An intravenous dose of 15 mg/kg of ATX between induction and incision, renewed at the end of surgery

No ATX

Proportion of patients using mild opioids

6 months:

I: 20.00%; C: 33.00%, p = 0.18

  Schroer 2011

USA [71]

Randomized controlled trial

107

67

58%

TKA

Celecoxib 200 mg to twice daily for 6 weeks after discharge

Placebo capsules

Number of opioid pills used (dosage NS)

12 months:

I: 76.30; C: 138.00, p = 0.003

  Cheesman 2020

USA [107]

Randomized controlled trial

140

58

32%

ARCR

Formal opioid education (recommended postoperative opioid use, side effects, dependence, and addiction) + a 2-minute computer-based presentation concerning opioid abuse and its consequences + a paper outline on the most important points of the presentation

Standard preoperative education followed by a discussion of risks and benefits. No formal education on opioid use, dependence, and addiction.

Total MED

24 months :

Total population:

I: 375.00; C:725.00

p = 0.27

Opioid-naïve patients:

I: 375.00; C: 535.00

p = 0.42

Prior opioid use:

I: 1,612.00; C:2,475.00

p = 0.57

Proportion of opioid dependence (6 opioid prescriptions from the date of surgery)

Total population:

I: 11.40%; C: 25.70%

p = 0.5

Opioid-naïve patients:

I: 3.70%; C: 16.70%

p = 0.04

Prior opioid use:

I: 37.50%; C: 47.60%

p = 0.78

No of prescriptions filled

Total population:

I: 2.90; C: 6.30

p = 0.03

Opioid-naïve patients:

I: 1.20; C: 3.40

p = 0.6

Prior opioid use:

I: 8.90; C: 13.20

p = 0.56

  Campbell 2019

USA [50]

Randomized controlled trial

159

60

45%

THA or TKA

Traditional perioperative education + automated text messages included recovery instructions paired with encouraging and empathetic statements, personalized video messages from their surgeon, and short instructional videos

Traditional perioperative education, which included a preoperative clinic appointment and perioperative instructions

Time to opioids cessation (days)

6 weeks:

I: 22.50; C: 32.40

Mean difference: -10.0, 95% CI -14.2-(-5.7), p < 0.001

  Smith 2018

USA [51]

Randomized controlled trial

561

66

60%

TKA or THA

Usual care + pharmacist intervention

Usual care: an educational session that advised patients on the risks and benefits of surgery, pain control measures and exercise recommendations.

Pharmacist intervention: mailed brochures describing what patients should expect regarding opioid use and pain control after and follow-up telephone call from a pharmacist.

Usual Care (handouts and a class in preparation for surgery that advised patients on the risks and benefits of surgery, pain control measures, exercise recommenda-tions, and the need for postsurgical assistance)

Total dispensing of opioid medications

3 months:

Adjusted mean difference for patients sociodemographics and probability of long-term opioid use: 0.92 95% CI 0.69-1.21

No readmission for pain control during the study period.

  Urban 2021

USA [108]

Retrospective cohort

267

67

63%

TKA

Preoperative cryoneurolysis (1 min 45 sec cycle in the infrapatellar branches of the saphenous nerve near the knee and branches of the femoral cutaneous nerves in the mid-to-distal anterior thigh + standard multimodal regiment.

Standard multimodal regiment (preoperative protocol + postoperative : oral acetaminophen 500 mg every 6 hours, oral meloxicam 7.5mg twice daily, oral tramadol 50 mg every 6 hours as needed for pain, oral oxycodone 5 mg every 3 hours as needed)

Cumulative MED

6 weeks:

Mean:

I: 894; C: 1,406.00

Ratio estimate : 0.64 95% CI 0.57-0.71, p < 0.001

Proportion of patients who received ≥1 prescription at 6 weeks

I: 12.00%; C: 20.00%

Ratio estimate : 0.61 95% CI 0.29-1.28, p < 0.19

  Buys 2020

USA [109]

Retrospective cohorte

336

65

10 %

RCR, THA, TKA, TSA (veteran population)

Implementation of a Transitional Pain Service. Multidisciplinary providers work together to deliver comprehensive pain management for any surgical patient at risk for CPSP and COU in preoperative, surgical hospitalization and postoperative period up to 6 months.

Before Transitional Pain Service implementation

Proportion of patients still using opioids

3 months:

Patients with history of COU

I: 33.40%; C: 23.30%

p = 0.002

Opioid-naïve patients

I: 0.70%; C: 8.40%

p = 0.004

  Li 2020

USA [110]

Prospective cohort

143

66

45%

TKA

Multimodal pain management + opioid PRN

Opioid-only analgesia

Cumulative MED

1 month:

Mean: I: 386.40; C: 582.50

p = 0.0006

Proportion of patients who required a refill

I: 51.40%; C; 74.60%

p = 0.004

  Fleischman 2019

USA [57]

Randomized controlled trial

235

63

46%

THA

I1: Multimodal analgesic regiment (acetaminophen 1000 mg tid x 4w + Gabapentin 200 mg bid x 4 w + Meloxicam 15 mg die x 2w + Omeprazole 20 mg die x 2 w) + narcotic for emergency pain relief only

I2: Multimodal analgesic regiment + narcotic as needed

No standing dose regimen (acetaminophen 500 mg QID PRN x 4w + Oxycodone q. 4h PRN + tramadol 50 mg q 6 hours PRN)

Cumulative MED

1 month:

I1: mean difference: -0.77, p < 0.001); I2: -0.30, p = 0.04 compared to C

I1: mean difference: -0.46, p = 0.002 compared to I2.

Proportion of patients who received opioid refill (%)

3 months:

I1: 10.50%; I2: 6.50%;

C: 15.60%, No significance test

Proportion of patients using opioids

I1: 0.00%; I2: 1.30%; C: 2.60%, No significance test

  Hannon 2019

USA [68]

Randomized controlled trial

304

65

54%

THA or TKA

Prescriptions of acetaminophen, meloxicam, gabapentin, tramadol, and 30 pills of 5 mg OxyIR (oxycodone) as a second breakthrough pain medication

Idem as experimental group and 90 pills of 5 mg OxyIR (oxycodone)

Cumulative MED

1 month :

I: 456.70; C: 455.60, p = 0.980

3 months:

I: 777.10; C: 1089.70, p < 0.001

Proportion of patients who received opioid OxyIR refill(s) (%)

3 months:

I: 26.70%; C: 10.50%, p < 0.001

  Padilla 2019

USA [84]

Retrospective cohort

669

65

58%

THA

Opioid sparing pain management protocol (intravenous acetaminophen, periarticular injection of liposomal bupivacaine, pre-emptive analgesia in postoperative period)

Before implementation of the opioid sparing protocol

Cumulative MED

3 months:

I: 13.90; C: 80.10, p < 0.001

  Tan 2018

Australia [58]

Prospective cohort

230

64

66%

THA

ERAS program (multimodal analgesia, early mobilization with physiotherapy)

Before ERAS implementation

MED/day

6 weeks:

I: 0.00; C: 0.00, p > 0.99

Proportion of patients using opioids (%)

The proportion of patients with zero MED consumption at week 6 increased from 56.60% to 80.00% (RR 1.34, 95% CI 1.13-1.58).

  Dasa 2016

USA [56]

Retrospective cohort

100

38

70%

TKA

Administering perioperative cryoneurolysis and multimodal analgesics regimen

Multimodal analgesics regimen alone.

Cumulative MED

3 months:

I: 2,069.12; C: 3,764.42,

p < 0.0001

  Bovonratwet 2021

USA [111]

Retrospective cohort

611

63

81%

THA

Direct anterior approach

Posterior approach

MED

No data available on the amount of prescribed or consumed opioids

Proportion of patients who required a refill

3 months:

I: 14.77%; C: 20.73:

p = 0.077

I relative to C:

relative risk = 0.95,

95% CI 0.55-1.64,

p = 0.864

  Varady 2021

USA [112]

Retrospective cohort

92, 506

57

52%

TJA

Outpatient (no overnight stay)

Inpatient

Proportion of new opioid persistent use (patient still filling opioid prescriptions >90 days postop)

3 months:

I: 8.20; C: 10.60 p < 0.001

OR, 1.21; 95% CI 1.11-1.32; p < 0.001

  Walega 2019

USA [61]

Randomized controlled trial

68

66

60%

Genicular nerve radiofrequency aoublation

Sham procedure: simulated GN-RFA using identical supplies and devices

MED/day

6 months:

I: 0.00; C: 0.00, p = 0.58

  Verla 2018

USA [60]

Retrospective cohort

46

58

54%

Spine surgery

Transforaminal lumbar interbody fusions

Direct lateral lumbar interbody fusions

Postoperative opioids duration in months

All level:

I: 5.20; C: 4.80, p = 0.82

L4-L5 only:

I: 4.30; C: 3.14, p = 0.5

  Della Valle 2010

USA [59]

Randomized controlled trial

72

63

68%

THA

Mini-incision approach

2 incisions approach

MED/day

6 weeks:

I: 1.30; C: 1.40, p = 0.79

  Collinsworth 2019

USA [54]

Randomized controlled trial

40

20

22%

Shoulder surgery

(military population)

Usual care and BFA (semipermanent acupuncture needles emplaced on the subjects’ ears for 3–5 days within 24 hours after shoulder surgery. BFA was reapplied, as needed, up to 6 weeks post-surgically)

Usual postsurgical care (include surgery specific protocols, therapeutic modalities and prescribed/ over-the-counter pain medications

Daily opioid use

6 weeks:

mean difference: 3.75, 95% CI -3.335-10.825, p = 0.29

  Hanley 2021

USA [113]

Randomized controlled trial

118

65

62%

THA, TKA

One 20 minutes session of mindfulness of breath (I1) or mindfulness of pain (I2) 3 weeks preop

One 20 minutes session of cognitive-behavioral pain psychoeducation (C)

Opioid use

Until 28 days postoperatively

Both MoB and MoP decreased postoperative opioid use relative to

C, F(8, 83) = 16.66, p < 0.001

  Hah 2020

USA [114]

Randomized controlled trial

104

66

52%

THA, TKA

Motivational interviewing and guided opioid tapering support added to usual care (phone call weekly for postoperative weeks 2-7 and monthly up to 1 year or to opioid cessation)

Usual care + standardized verbal and written instructions on the proper analgesic use of opioids before surgery

Time to base line opioid use return (days)

I: 34.60; C: 67.80,

HR 1.62; 95% CI 1.06- 2.46; p = 0.03

Proportion of patients using opioids at 3 months

Overall: I: 2.70%; C:2.00, p > 0.05

Opioid naïve:

I: 2.70%; C: 9.50%, p > 0.05

Preoperative user:

I: 8.30%; C: 23.10%, p > 0.05

Proportion of patients using opioids at 6 months

Overall:

I:0.00%; C:5.50%, p > 0.05

Opioid naïve:

I: 0,00%; C: 2,40%, p > 0.05

Preoperative user:

I: 0.00%; C: 15.40%, p > 0.05

Time to postoperative opioid cessation (days)

I: 41.1; C: 76.4 HR 1.57; 95% CI 1.01- 2.44; p = 0.05

Proportion of opioid cessation

I: 91.80%; C: 87.3%, p = 0.5

  Dindo 2018

USA [95]

Randomized controlled trial

75

63

6%

Orthopedic surgeries (no trauma)

Acceptance and Commitment Therapy (ACT) and treatment as usual

Treatment as usual (a nurse-led patient education class + analgesia with opioids +/- nonopioids, anticonvulsants or anxiolytics regular or as need. Discharge combination of an opioid and acetaminophen

Time to opioid cessation (days)

I: 42.50; C: 51.00;

HR 1.44, 95% CI 0.74-2.78

Proportion of patients using opioids

At 7 weeks:

I: 29.00%; C: 52.00%,

OR= 0.39; 95% CI 0.14-1.08