Choosing Wisely:

Avoid routine use of opioids for treatment of knee osteoarthritis, hip osteoarthritis, low back pain, or rotator cuff injury.

Rationale and Comments: The use of opioids is not recommended without a thorough evaluation, consideration of alternative medications and treatments, review of all current medications, and discussions of risks of opioid therapy and potential interactions with current medications for other conditions. Other treatment modalities are effective and avoid the risks associated with the use of opioids. Opioid prescriptions should be for a limited period with the lowest effective dose that provides meaningful pain relief and improved function with manageable side effects.
Sponsoring Organizations:
  • American Academy of Orthopaedic Surgeons
  • Sources:
  • Randomized controlled trials
  • Disciplines:
  • Neurologic
  • Orthopedic
  • Rheumatologic
  • References: • Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872-882.
    • Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine. 2007;32(19):2127-2132.
    • Dowell D, Haegrich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49.
    • Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
    • Kivitz AJ, Moskowitz RW, Woods E, Hubbard RC, Verburg KM, Lefkowith JB, Geis GS. Comparative efficacy and safety of celecoxib and naproxen in the treatment of osteoarthritis of the hip. J Int Med Res. 2001;29(6):467-479.
    • Makarowski W, Zhao WW, Bevirt T, Recker DP. Efficacy and safety of the COX-2 specific inhibitor valdecoxib in the management of osteoarthritis of the hip: a randomized, double-blind, placebo-controlled comparison with naproxen. Osteoarthritis Cartilage. 2002;10(4):290-296.
    • Svensson O, Malmenas M, Fajutrao L, Roos EM, Lohmander LS. Greater reduction of knee than hip pain in osteoarthritis treated with naproxen, as evaluated by WOMAC and SF-36. Ann Rheum Dis. 2006;65(6):781-784.
    • Fishman RL, Kistler CJ, Ellerbusch MT, et al. Efficacy and safety of 12 weeks of osteoarthritic pain therapy with once-daily tramadol (Tramadol Contramid OAD). J Opioid Manag. 2007;3(5):273-280.
    • Bookman AA,Williams KS, Shainhouse JZ. Effect of a topical Diclofenac solution for relieving symptoms of primary osteoarthritis of the knee: a randomized controlled trial. CMAJ. 2004;171(4):333-338.
    • Fleischmann RM, Caldwell JR, Roth SH, Tesser JRP, Olson W, Kamin M. Tramadol for the treatment of joint pain associated with osteoarthritis: a randomized, double-blind, placebo-controlled trial. Current Therapeutic Research, Clinical & Experimental. 2001;62:113-128.
    • Clendenen SR, Rajendran S, Kopacz DJ, Greengrass RA, Robards CB, Weinstein DM, Brodersen MP, Ortiguera CJ, Crook J, Logvinov II. Pregabalin as an adjunct to a multimodal analgesic regimen to achieve opioid sparing in arthroscopic rotator cuff repair. J Rom Anesth Terap Int. 2010;17:5-10.
    • Han SS, Lee YH, Oh JH, Aminzai S, Kim SH. Randomized, controlled trial of multimodal shoulder injection or intravenous patient-controlled analgesia after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2013;21(12):2877-2883.
    • Perdreau A, Joudet T. Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair. Orthop Traumatol Surg Res. 2015;101(8 Suppl):S337-S345.
    • Syed UAM, Aleem AW, Wowkanech C, Weekes D, Freedman M, Tjoumakaris F, Abboud JA, Austin LS. 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 Elbow Surg. 2018;27(6):962-967.

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