Effects of preoperative opioid education on postoperative opioid use and pain management in orthopaedics: A systematic review

Abstract

Prescription opioid abuse after surgery is considered a crisis in the United States. The objective of this systematic review was to evaluate use and effectiveness of pre-operative education with respect to post-operative opioid use and management of pain in the orthopaedic setting. Electronic searches were conducted in Ovid/Medline and SCOPUS to identify articles that discuss pre-operative opioid education and its effects on post-operative pain scores and prescription fulfillment. Non-orthopaedic studies were included for comparison. Eleven studies met inclusion criteria, 3 of which were retrospective reviews of large (>1000) post-surgical cohorts, and 8 of which were randomized controlled studies that examined different approaches to opioid education. Best current evidence suggests that incidence of opioid abuse after surgery is 5.9–6.5% and that the internet is the main source of guidance for patients regarding postoperative pain management. Education specifically related to opioid use and pain can be effective in reducing opioid prescription requests and filling. In contrast, education related solely to postoperative expectations does not consistently impact post-operative pain scores and was associated with 44% of total joint arthroplasty patients stating the approach was unhelpful regarding their pain management. This systematic review suggests that it is most effective to give patients verbal information rather than only providing information in written form and that utilizing two forms of education is most effective. The current literature supports this multi-modal approach to preoperative opioid education preoperatively for reducing post-operative opioid use and severity of self-reported pain.

1. Introduction

The opioid epidemic is considered a healthcare crisis in the United States. Approximately 30,000 people die annually from opioid or heroin overdoses, and the number of opioid-related fatalities is expected to continue to increase unless effective management strategies are implemented.¹ The start of this epidemic is often attributed to an op-ed article published in the New England Journal of Medicine in 1980, which stated that opioid addiction was rare based on the authors’ statement that they only identified 4 of nearly 12,000 hospitalized patients who developed a post-operative opioid addiction.² This opinion-based article provided no peer-reviewed evidence for this provocative assertion but was still widely used to justify prescription of opioids to treat pain from many causes as common practice in the United States.³ This shift in practice has been associated with exponential increases in opioid prescriptions without a concurrent focus on physician or patient education regarding side effects and risks for abuse, overdose, and addiction.

The common side effects associated with opioid use include nausea, sedation, constipation, and lowered sex drive, while common risks include drug tolerance and dependence, as well as hyperalgesia.⁴ In stark contrast to Porter and Jick's anecdotal claims regarding risk for addiction, recent peer-reviewed studies document a 5.9%–6.5% risk for chronic opioid use in patients who are prescribed a 90–120 day supply of opioids for post-operative pain.^2,5,6 In addition, other individuals with access to patients' opioids are also at significant risk.⁷ In fact, most teenagers who use opioids for non-medical use access these drugs from their parents' medicine cabinet, highlighting the lack of education with respect to proper storage and disposal of these prescription medications.⁸

Opioid use among orthopaedic surgery patients is an especially important area of study. Complications from chronic opioid use in orthopaedic patients have included a higher risk of falls for the elderly,⁹ adverse outcomes,¹⁰ and ineffective pain relief.¹¹ Orthopaedics was ranked third in a study reporting which providers prescribed the most opioids, and though opioid prescription rates are trending down for healthcare providers in orthopaedics, the numbers are still well above the national average and significantly higher than for orthopaedic providers in other developed countries.¹²

To date, efforts to reduce opioid use and addiction have mainly focused on reducing patients’ need for opioids to control pain after surgery. Implemented methods include multimodal analgesia protocols, management of patient anxiety, and/or addressing patient expectations with “pain contracts.” These methods have had positive impact, however, the relatively simple, readily accessible and cost effective strategy to use education to enhance patient safety by reducing prescription opioid use and addiction has received little attention.^13,14 Therefore, the objective of this study was to systematically review the peer-reviewed evidence regarding pre-operative patient education related to opioids to identify effective strategies that can be optimized through further development, validation, and implementation in orthopaedic surgery. These efforts could ultimately accomplish the overarching goal of decreasing opioid use, abuse, addiction and related costs, morbidity, and mortality.

2. Methods

2.1. Data sources

Ovid/Medline and SCOPUS were reviewed for relevant, peer-reviewed articles in the English language for all publication years available through August of 2019. Keywords used in these searches were narcotics, opioids, preoperative (period, care), (patient) education, counseling, and pain management. The reference lists of articles identified by this search were also reviewed for inclusion. A secondary search was conducted in Ovid/Medline alone to identify a baseline understanding for opioid addiction after surgery by using the keywords postoperative AND opioid addiction.

2.2. Study selection and data extraction

The titles, abstracts, and reference lists of articles identified through the search were reviewed by the primary reviewer. Articles identified in the primary search were eligible for inclusion if they discussed pre-operative education or counseling, specifically in relation to opioids. Articles were excluded if they did not provide follow-up after discharge or if they discussed education related to post-operative pain expectations without specific education regarding opioids/opioid use disorder risks. Because of the relatively small sample size of articles specifically related to orthopedics, other specialties were included as long as they fit the other criteria. The following information was extracted from the studies: method for educating patients, sample size, type of study, information and/or examples of education provided, and outcomes.

Bias was difficult to measure. Studies that seemed to discuss pain or opioids without addressing risk factors and did not seem to base their recommendations based on scientific findings were considered to be more biased than those that simply provided education on facts surrounding opioids and their use.

The primary measure assessed was postoperative opioid use and the secondary measure assessed was type of education employed. Based on differences in opioid use metrics and variability in educational methods among studies, each study was assessed individually with similarities extracted by the reviewer for application to standardization of future work.

Articles identified through the secondary search were included if they provided incidence of opioid addiction in a population of patients greater than 10,000 and specified a definition for chronic opioid addiction.

3. Results

The primary search identified 240 articles of which 8 met criteria for inclusion. The search yielding the most directly related results was narcotics OR opioids AND preoperative education. The reference lists of these included studies were also searched, and 3 additional studies were included in this systematic review (Table 1). Of the 11 articles included, 3 were large (1017–641,941 subjects) retrospective reviews regarding opioid addiction in relation to preoperative education impression of patients. The remaining 8 articles were randomized, or quasi-randomized, controlled studies that evaluated the effects of specific methods for pre-operative opioid education of patients on postoperative use of medications and patient outcomes. Five of the eleven studies were specific to orthopaedics, two addressed elective procedures that could include orthopaedic procedures, and four were not related to orthopaedics but satisfied inclusion criteria and provided relevant data for application to orthopaedics.

Table 1.

Preoperative opioid education studies.

Study	Sample Size	Study Design	Intervention Tested	Type of Surgery	Outcomes
Angioli, R et al.	190	Prospective Randomized	Groups were given either verbal or written pre-operative information about pain	Gynecologic Oncology Surgery	Significantly higher satisfaction, lower VAS, lower number of days inpatient, and lower use of pain medication in group receiving written information
Chen, S et al.	92	Prospective Randomized	Experimental group was given a health education CD and pamphlet, verbal instructions preoperatively, and enhanced postoperative instructions vs. control group that only received verbal instructions preoperatively	Total Knee Arthroplasty	Pain scores for the first 2 days after surgery were significantly lower in patients that were in the experimental group
Kurup, V et al.	1039	Retrospective	Survey of surgical patients to assess their knowledge and source of information regarding pain and pain control	Elective Surgery (type not specified)	57% of patients were concerned about experiencing pain postoperatively, 17% had utilized the internet to gather information related to pain and pain control
Lemay, C et al.	1609	Retrospective	Survey of surgical patients regarding information received regarding pain management prior to surgery	Total Joint Arthroplasty	44% of patients reported either unhelpful or no information regarding pain management prior to surgery, these patients were associated with worse outcomes at 6 months post-op
Louw, A et al.	1017	Systematic Review	13 controlled trials comprising 1017 THA and TKA patients that utilized different educational methods and content prior to surgery	Total Joint Arthroplasty	Pre-op education focused on anatomy and procedural information did not improve post-operative pain management. The study recommends covering pain science, pain management, and communication skills as the studies that did this showed a correlation to lower pain after surgery
O'Donnel, KF	24	Prospective Randomized	Patients in the experimental group received one-on-one verbal education about pain and opioids vs. control that did not receive any verbal or written education before their cholecystectomy	Outpatient Cholecystectomy	92% of patients reported severe pain after surgery, Patients in the experimental group reported significantly lower amount of pain
Sugai, DY et al.	135	Prospective Randomized	The experimental group had two in-person educational sessions focused on “endorphins” and “natural narcotics” as well as risks and side-effects vs the control group that did not receive any pre-operative oral or written education.	Elective outpatient aesthetic procedures	10% of patients in the experimental group vs. 100% of patients in the control group filled a prescription for hydrocodone at 2 weeks post-op
Syed, UAM et al.	140	Prospective Randomized	Patients in the experimental group received opioid related preoperative education including a video and handout vs. control that received education regarding surgery.	Arthroscopic Rotator Cuff Repair	Patients in the experimental group received significantly less narcotics than the control. Additionally, the experimental group was more likely (2.2x) to stop narcotic use before the follow-up period of 3 months was complete.
van Dijk, JF et al.	507	Prospective Quasi-randomized	The experimental group watched an educational film on pain treatment, pain assessment, and postoperative pain vs the control group that watched a control film about the hospitals information system	Elective surgery (ENT, Neuro, Ortho, Plastic, Urology, Eye, Vascular, Cardiothoracic)	Patients in the experimental group had a better understanding of opioids and significantly lower pain scores using the same amount of opioids as patients in the control group
Watt-Watson, J et al.	225	Prospective Randomized	Patients in the experimental group were given a “pro pain relief” booklet on pain medication and pain control after surgery not intended to decrease use of opioids. vs control that did not receive a booklet prior to coronary artery bypass surgery	Coronary artery bypass graft surgery	No significant differences were found between experimental and control groups
Wilson RA et al.	143	Prospective Randomized	Patients undergoing TKA were divided into two groups. The experimental group was provided with a booklet, a one-on-one teaching session, and a telephone call about broad symptom management vs. control which had the standard of care protocol.	Total Joint Arthroplasty	Individualizing education content was insufficient to produce a change in symptoms for patients after TKA

Table 1 contains articles that studied the effects of various educational methods conducted preoperatively on pain/opioid use and the effect these interventions had on post-operative pain scores and opioid use. For each study, the number of subjects, the type of surgery, the details of the intervention, and the primary outcomes are listed.

Two articles met inclusion criteria for the secondary search aimed at determining incidence of post-operative opioid addiction (Table 2).

Table 2.

Postoperative opioid abuse studies.

Study	Sample Size	Study Design	Chronic Opioid Use Definition	Outcomes
Sun, E et al.	641,941	Retrospective	10 or more prescriptions or more than 120-day supply	5.1% incidence of chronic opioid use after TKA surgery
Brummet, C et al.	36,177	Retrospective	More than 90 days	5.9–6.5% incidence after minor or major surgery

Table 2 contains articles that were used to develop a working definition of post-operative opioid abuse and incidence.

3.1. Incidence

In a retrospective review of 641,941 patients who were privately insured and had total knee arthroplasty between 2001 and 2013, the incidence of chronic opioid addiction was 5.1%. These authors defined addiction as a patient having 10 or more prescriptions or more than a 120-day supply of opioids. Risk factors associated with opioid addiction in this cohort included being male, patient age greater than 50 years, history of drug or alcohol addiction, depression, and antidepressant medication use.⁶

Another retrospective review of 36,177 patients who underwent minor surgery (e.g., carpal tunnel or laparoscopic appendectomy) or major surgery (e.g., hernia repair, bariatric surgery, or hysterectomy) reported an incidence of opioid addiction as high as 6.5%. These authors defined addiction as use of opioids for more than 90 days, and reported that degree of surgery—minor versus major—did not significantly affect incidence of postoperative opioid addiction. Instead, risk factors for opioid addiction in this study included tobacco use, alcohol abuse, substance abuse, mental health issues, and pain disorders.⁵

Using these large-scale studies as reference standards, opioid misuse for this systematic review was defined as utilizing opioids for more than 90 days after surgery.

3.2. Effects of preoperative education

Studies assessing preoperative education in this systematic review varied in type of intervention, educational content and method of delivery. Kurup et al.¹⁵ and Lemay et al.¹⁶ conducted reviews of the information received by patients presenting to a pre-operative clinic, gauging the patients’ impressions of that information. Kurup reported that 57% of 1039 patients surveyed stated they were concerned about their postoperative pain and 55% of patients did not cite anyone identified to them as specifically responsible for managing their pain following unspecified elective surgery. A small subset (16.7%) of patients used the Internet to learn more about pain control, with age under 60 being a predictive factor for use of this source. Roughly half (48%) of the patients who used the Internet as a resource said they were happy with the information they found regarding pain control. In this same study, 124 (11.9%) of those surveyed reported taking opioids for more than 3 months after their unspecified elective surgery. Lemay reported that 33% of patients stated that they did not receive information about managing their pain before their total joint replacement surgery, and another 10.6% stated that the information they received was not helpful. Patients who received helpful pre-operative information on pain were significantly more likely to have lower pain scores at their 2 week follow-up visit after surgery, were also more likely to use one non-medication method (such as ice) to relieve joint pain, and were more likely to have higher function at 6 months after surgery. Taken together, these studies suggests that patients are concerned about pain such that they seek out information, often from the Internet, and support preoperative education on pain and pain management as having high potential to decrease opioid use after elective surgeries including total joint arthroplasty. Louw et al. concluded that patients could also realize a reduction in pain after total joint arthroplasty when they feel that the preoperative education received was beneficial.

A major factor in successful reduction of opioid use through preoperative education was educational content. Watt-Watson et al.¹⁸ utilized a booklet aimed at ensuring effective pain management, stating “It is important for you to have as little pain as possible … good treatments are available to help relieve pain, especially medications after surgery,” and citing a statistic claiming that opioid addiction should not be a concern since it occurs less than 0.01% of the time. This method and content were associated with no significant differences in amount of opioids used or degree of pain reported for patients undergoing coronary artery bypass surgery. Wilson et al.¹⁹ used similar method and content to compare preoperative education for total knee arthroplasty patients and also reported no significant differences for the cohort receiving this preoperative education. van Dijk et al.²⁰ implemented a DVD-based preoperative education program to inform patients on how to use the numeric rating scale pain assessment for requesting opioids. The educational video did not contain information about side effects or risks associated with opioids. While patients who watched the educational video reported a better understanding of pain control, opioid use after elective surgeries was not significantly different from patients who did not watch the educational video.

In contrast, studies that provided preoperative education specific to appropriate opioid use consistently reported significant reductions in postoperative opioid consumption. Studies that discussed how the body creates “natural narcotics”, risks of taking opioids long term, and/or proper use expectations post-operatively were associated with the greatest reductions in opioid use.^21,22 Importantly, these specific educational components also corresponded to lower self-reported pain scores after surgery.

With respect to delivery method, studies varied between booklets, videos, and in-person education, or a combination approach. Studies reporting highest efficacy employed a two-fold approach to delivering the education utilizing either a handout and in-person educational session or a handout and video, and provided evidence for use of written education being associated with superior outcomes in terms of hospitalization days, self-reported pain scores, and pain medication usage compared to those receiving only verbal education.^23,24,26 Table 3 delineates delivery methods for included studies in conjunction with reported success. While best current evidence is not conclusive as to whether method of delivery or educational content is most influential, the majority of studies that reported successful reduction in post-operative opioid use and self-reported pain used similar content with varying methods of delivery, suggesting content is more important than delivery method in realizing these goals for preoperative education. As long as educational content included discussion of opioid risks and side effects and at least two methods of delivery were employed, preoperative education was effective in accomplishing its goals.

Table 3.

Method of education and outcome.

	Written AND Verbal	Verbal Only	Written & Video	Video Only	Written Only
# of Studies Utilizing	3	2	1	1	1
# of Studies Citing Successfully lowered opioid use	2	2	1	1	0

Table 3 shows the randomized controlled trials that looked at both opioid use and educational tactics, showing how many studies tried each kind of intervention, and which of those studies cited successful results.

4. Discussion

This systematic review of best current evidence regarding pre-operative patient education regarding postoperative opioid use in orthopaedics suggests that incidence of opioid abuse remains unacceptably high, but that effective educational content delivered in at least a written form can reduce postoperative use of opioids while also improving patients’ perception of pain. However, these findings are based on relatively little evidence due to the paucity of studies focused on this important topic that are published in peer-reviewed journals. As opioid use among orthopaedic healthcare providers remains high and complications from chronic opioid use in orthopaedic patients can be especially devastating, it is imperative that orthopaedic centers investigate, assimilate, and apply effective strategies for combating this major healthcare concern.

In 2011, the Institute of Medicine published “Relieving Pain in America,” which supported utilizing multi-modal education preoperatively to optimally manage pain while mitigating side effects, risks, and abuse of medications. The results of the present systematic review suggest that this proposed course of action has not been fully adopted or enacted in orthopaedics even in the face of what is considered a national epidemic. Multiple studies have documented that incidences of opioid addiction and abuse are significantly higher than previously suggested, and that education for patients and healthcare providers regarding risks for opioid mismanagement have been insufficient.^17,28, 29, 30 It is now clear that patients who use prescribed opioids to manage their postoperative pain have a 5.1%–6.5% risk for chronic opioid dependency.

In general, studies meeting inclusion criteria for this systematic review support preoperative education as consistently effective in reducing postoperative opioid consumption when it specifically discusses appropriate opioid use and risks and is provided using a multi-modal approach (written and in-person). Included studies also reported that providing information about pain pathways and “natural narcotics” is effective at reducing opioid use as long as it is coupled with information about opioids and their role in appropriate pain relief.

Unfortunately, one of the major findings from this systematic review was that there is a paucity of available research focused on education-based methods for reducing postoperative opioid use and abuse, especially in the field of orthopaedics. This lack of evidence may be due to misconceptions that have been propagated in the United States regarding pain management expectations and incidence of opioid abuse and addiction.²⁷ As such, there is a critical unmet need in orthopaedics that needs to be addressed through targeted research aimed at cost effective and readily available methods for combating the opioid epidemic. Preoperative education is one such method, which this systematic review supports as having high potential for helping to address the critical unmet need in orthopaedics.

The results of this systematic review suggest that areas for research focus should include further examination regarding the impact of preoperative education in relation to patients with mental health issues²⁵ history of opioid use disorders²⁶ substance abuse, and pain disorders.⁵ More robust evidence is also needed regarding educational content, delivery method, timing and duration. In order to implement the findings of the present study in order to make progress while awaiting additional evidence, it is recommended that orthopaedic healthcare teams institute a multimodal education program for verbal discussion of opioid use, side effects and abuse and expectations for pain management when patients are being consented for surgery. Educational handouts reinforcing the discussion should be provided so that patients have a tangible way of remembering what was discussed.

This systematic review was limited by the number of available peer-reviewed publications that focused on preoperative education on opioids and post-operative use. There was little consistency in content, study length, or method of education across studies meeting inclusion criteria, which made it difficult to draw conclusions. Further, sample sizes were small for the prospective randomized trials. This prevented effective meta-analysis and limited evidence based application of available data. In terms of bias, there were a few studies conducted by surgeons that sought to educate patients to utilize pain medications for comfort (i.e., Watt-Watson) that could potentially be considered biased based on the wording in the educational documents. These studies were performed during the “boom” of opioids, and therefore they approach the topic in a different manner than more recent studies. The wording of these studies was discussed in this review, and the articles included in the analysis as comparison.

It is imperative that strategies to address the profound and growing problem of opioid abuse and addiction in the US be devised, tested, validated and implemented. Preoperative education programs hold promise as an effective strategy for this purpose and need to be the focus of target research aimed at protecting patients and improving healthcare in this country. The impetus for further research is clear when one considers the continually rising death toll from opioid overdoses and the high prescriber status of orthopaedic physicians. The hope is that as research and education advance, the incidence of opioid addiction and overdose deaths decline significantly and opioids can be used in a more appropriate manner that balances pain relief postoperatively with long-term safety. While no concrete management protocol can be definitively outlined from this systematic review, it is clear that preoperative education can be consistently successful in reducing postoperative opioid use and self-reported pain. As such, orthopedic healthcare teams should take the necessary steps to implement open and clear communication with patients with respect to pain management expectations and opioid risks and benefits prior to surgery. These education and communication partnerships can save lives, improve outcomes, and decrease healthcare costs, as well as positively impact patient satisfaction.

Declaration of competing interest

No conflicts of interest to report at this time by the authors.