American Academy of Orthopaedic Surgeons

View all recommendations from this society

Released May 15, 2020

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

The use of opioids is not recommended without a thorough evaluation, consideration of alternative medications, 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.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

(1–5) The American Academy of Orthopaedic Surgeons (AAOS) routinely develops evidence-based clinical practice guidelines as valuable tools to advance the physician-patient communications process and enhance the diagnosis and treatment of musculoskeletal conditions. AAOS physician volunteer work groups develop evidence-based clinical practice guidelines to serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment. The most recent approved clinical practice guidelines have been published in the Journal of Bone and Joint Surgery. AAOS staff, led by the medical director, conducted a review of the approved clinical practice guidelines previously developed by the work groups and selected a variety of topics frequently used in orthopaedic surgical practice. After input from the orthopaedic specialty society leaders and approval from the AAOS Presidential Leadership and Board of Directors, the final five topics were selected for this campaign. The AAOS disclosure and conflict of interest policy can be found at www.aaos.org.

(6-10) The American Academy of Orthopaedic Surgeons (AAOS) routinely develops evidence-based clinical practice guidelines as valuable tools to advance the physician-patient communications process and enhance the diagnosis and treatment of musculoskeletal conditions. AAOS physician volunteer workgroups develop evidence-based clinical practice guidelines to serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment. AAOS staff methodologists conducted a review of the approved clinical practice guidelines previously developed by the workgroups and selected a variety of topics frequently used in orthopaedic surgical practice. After input and approval from the AAOS Committee on Evidence-Based Quality and Value, followed by the approval from the AAOS, Council on Research and Quality and AAOS Board of Directors, the final five topics were selected for this campaign. The AAOS disclosure and conflict of interest policy can be found at www.aaos.org/quality.

Sources

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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 Sep 1;32(19):2127–32.

Dowell D, Haegrich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United Stated, 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. Annals of Internal Medicine. 2017;166(7):514-530.

Kivitz,A.J.; Moskowitz,R.W.; Woods,E.; Hubbard,R.C.; Verburg,K.M.; Lefkowith,J.B.; Geis,G.S. Comparative efficacy and safety of celecoxib and naproxen in the treatment of osteoarthritis of the hip. J Int Med Res; 2001/11: 6

Makarowski,W.; Zhao,W.W.; Bevirt,T.; Recker,D.P. 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; 2002/4: 4

Svensson,O.; Malmenas,M.; Fajutrao,L.; Roos,E.M.; Lohmander,L.S. Greater reduction of knee than hip pain in osteoarthritis treated with naproxen, as evaluated by WOMAC and SF-36. Ann Rheum. Dis; 2006/6: 6

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. PM:18181382

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, S. R., Rajendran, S., Kopacz, D. J., Greengrass, R. A., Robards, C. B., Weinstein, D. M., Brodersen, M. P., Ortiguera, C. J., Crook, J., Logvinov, I. I. Pregabalin as an adjunct to a multimodal analgesic regimen to achieve opioid sparing in arthroscopic rotator cuff repair. Jurnalul Roman de Anestezie Terapie Intensiva/Romanian Journal of Anaesthesia and Intensive Care 2010; 1: 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 surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2013; 12: 2877-83

Perdreau, A., Joudet, T. Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair. Orthopaedics & traumatology, surgery & research 2015; 8: S337-45

Syed, U. A. M., Aleem, A. W., Wowkanech, C., Weekes, D., Freedman, M., Tjoumakaris, F., Abboud, J. A., Austin, L. S. Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial. Journal of Shoulder and Elbow Surgery 2018; 6: 962-967