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Opioids and the management of musculoskeletal conditions

Musculoskeletal conditions represent a significant portion of patient visits to primary care providers in the United States. Management of acute and chronic musculoskeletal conditions can be challenging for both primary care providers and for specialty providers. Opioid medications are used more commonly to treat musculoskeletal conditions, including osteoarthritis. The expansion of indications for opioids has led to a significant increase in opioid prescribing in the United States. The United States comprises less than 5% of the world’s population yet consumes nearly all of the world’s prescription opioid supply (80% of the global opioid supply, including 99% of the global hydrocodone supply).1

Patient-reported pain in the outpatient setting has remained relatively unchanged over the last decade, yet there have been significant increases in opioid prescriptions for pain.2 The increase in opioid prescriptions for pain has not been met with similar increases in nonopioid alternatives such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.2

The proliferation of opioid prescribing has led to many unanticipated consequences. Diversion of opioids for nontherapeutic use has led to significant increases in opioid addiction and unintentional overdose deaths. Opioid-related deaths are now more common that heroin, cocaine, suicide, and motor vehicle related deaths.3 The unfortunate impact of nontherapeutic opioid use is evident; however, the negative impact of therapeutic opioid use for the treatment of musculoskeletal conditions is now being recognized as well.

Preoperative opioid use for patients with knee osteoarthritis has been associated with significantly worse outcome scores, increased postoperative complications, and prolonged recovery following total knee arthroplasty.4 Preoperative opioid use prior to spine surgery has been associated with worse postoperative outcomes, increased length of stay, increased intraoperative and postoperative opioid demand, and decreased opioid independence one year after surgery.5-7

Similar results have been noted following total shoulder arthroplasty and reverse shoulder arthroplasty in patients with a history of preoperative opioid use for shoulder arthritis. Preoperative opioid was associated with significantly worse preoperative and postoperative shoulder function scores relative to patients without a history of preoperative opioid use.8,9 Patients with preoperative opioid use can respond very well to shoulder replacement surgery, but it has been shown that they do not reach the same level of improvement compared to nonopioid patients. Furthermore, patients without preoperative opioid use have been shown to have significantly better postoperative patient satisfaction after total shoulder arthroplasty compared to patients with preoperative opioid use.8

The American Academy of Orthopaedic Surgeons (AAOS) recently issued a position statement in response to the rise in opioid prescribing to help guide physicians that manage musculoskeletal conditions.10 The AAOS recognized the need for physicians to manage musculoskeletal pain, while understanding the direct and indirect contributions to the opioid burden in the United States.

The AAOS called for a culture change among physicians, patients, and caregivers regarding opioid prescribing and pain control in musculoskeletal conditions. Proposals included standardized opioid prescribing protocols, limits on the duration and amount of opioid pills prescribed, and avoiding the use of extended-release opioids. The AAOS recommended avoiding opioids for the routine management of pre-surgical pain, nonoperative, or chronic musculoskeletal conditions. Objective risk assessment tools were suggested to help better identify patients at risk for greater opioid use as well as opioid use tracking. Improved care coordination and physician collaboration was recommended. Orthopaedic surgeons and other musculoskeletal specialists can help to better communicate and collaborate with primary care physicians and other specialties regarding the treatment of musculoskeletal conditions.

The negative consequences of nontherapeutic opioid use are apparent. The detrimental effects of therapeutic opioid use, especially in the management of musculoskeletal conditions, are now more clearly identified. Additional work is needed to better understand and treat pain associated with musculoskeletal conditions. The association between therapeutic opioid use and worse patient outcomes has been highlighted. Additional efforts are needed to explore the complexities of pain and outcomes in the management of these common conditions.

Bibliography:
1. Manchikanti L, Singh A: Therapeutic opioids: A ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 2008;11(2 suppl):S63-S88.

2. Daubresse M, Chang HY, Yu Y, Viswanathan S, Shah ND, Stafford RS, Kruszewski SP, Alexander GC. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care 2013;51(10):870-878.

3. Manchikanti L, Helm S II, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid epidemic in the United States. Pain Physician 2012;15(3 suppl):ES9- ES38.

4. Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am 2011;93(21):1988-1993.

5. Lee D, Armaghani S, Archer KR, Bible J, Shau D, Kay H, Zhang C, McGirt MJ, Devin C. Preoperative opioid use as a predictor of adverse postoperative self-reported outcomes in patients undergoing spine surgery. J Bone Joint Surg Am 2014;96(11):e89.

6. Armaghani SJ, Lee DS, Bible JE, Shau DN, Kay H, Zhang C, McGirt MJ, Devin CJ. Increased preoperative narcotic use and its association with postoperative complications and length of hospital stay in patients undergoing spine surgery. Clin Spine Surg. 2016 Mar;29(2):E93-8.

7. Armaghani SJ, Lee DS, Bible JE, Archer KR, Shau DN, Kay H, Zhang C, McGirt MJ, Devin CJ. Preoperative opioid use and its association with perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery. Spine (Phila Pa 1976). 2014 Dec 1;39(25):E1524-30.

8. Morris BJ, Sciascia AD, Jacobs CA, Edwards TB. Preoperative opioid use associated with worse outcomes after anatomic shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25:619-623.

9. Morris BJ, Laughlin MS, Elkousy HA, Gartsman GM, Edwards TB. Preoperative opioid use and outcomes after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(1):11-16.
10. American Academy of Orthopaedic Surgeons Information Statement: Opioid use, misuse, and abuse in orthopaedic practice. http://www.aaos.org/positionstatements/statement1045/ Accessed March 22, 2016.

By Brent J. Morris, MD
Shoulder & Elbow Surgeon
Lexington Clinic Orthopedics – Sports Medicine Center
The Shoulder Center of Kentucky

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