Effectiveness of Perioperative Opioid Educational... : Anesthesia & Analgesia (2024)

KEY POINTS

Question: What is the impact of perioperative opioid education on opioid consumption patterns after hospital discharge (ie, number of pills, cessation, and prescription refills)?
Findings: There was a significant reduction in the number of opioid pills consumed within 15 days after surgery among those patients who received opioid education, but there was no impact on opioid cessation or refills within 15 days, 6 weeks, and 3 months.
Meaning: Perioperative educational interventions may reduce opioid consumption after hospital discharge, but it does not impact cessation or prescription refills.

See Article, p 938

Patients undergoing surgery are frequently exposed to opioids during hospitalization and continue to take these medications after discharge.^¹ In the United States, approximately two-thirds of ambulatory patients are prescribed opioids at discharge,^² and more than half of these prescriptions remain unused.^³ This phenomenon has contributed to a national opioid crisis with mental health and economic burdens for the health care system and adverse consequences on patient outcomes including risks of addiction, misuse, dependency, and diversion.^⁴ As a result, institutions have undertaken strategies to combat this crisis by minimizing opioid prescriptions,^⁵ using opioid-sparing analgesic modalities, and implementing educational interventions.^⁶^,^⁷ Patient education is a process of influencing patient behavior that will ultimately produce changes in knowledge, attitudes, and skills.

Although perioperative opioid education and counseling have demonstrated benefits in terms of patient satisfaction, safe behaviors, and psychological outcomes,^⁸ most systematic reviews have been limited to assessing qualitative evidence.^⁹ Some clinical trials have demonstrated the effectiveness of perioperative opioid education in reducing opioid use after hospital discharge^¹⁰^,^¹¹; however, other trials have yielded varying results and warrant further evaluation of the literature.^¹²^,^¹³ The goal of our study was to evaluate the impact of education on opioid consumption, opioid cessation and opioid refills, and appropriate disposal of unused opioids after hospital discharge.

METHODS

This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.^¹² It is registered in the International Prospective Systematic Reviews Registry database.

Literature Search Strategy

MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases were searched from inception to September 2020 for randomized studies, assessing the impact of perioperative opioid education on opioid consumption after hospital discharge. Our search strategy is explained in detail in Supplemental Digital Content, File, https://links.lww.com/AA/D578. Boolean operators were used to adapt the search strategy based on the database. In addition, citations were reviewed to ensure inclusion of relevant studies not captured in our initial literature search. Two authors reviewed and extracted the data independently (AZV and BHL). Full-text articles that met inclusion criteria were reviewed for detailed comprehension and further assessment of the quality and risk of bias. We excluded trials assessing education interventions in nonsurgical patients. All disagreements between reviewers in the selection and evaluation processes were resolved by discussion with a third reviewer (CLW). All demographic data, including year of publication, sample size, type of educational strategy, type of surgery, and specified outcomes, were abstracted to a predefined proforma.

Eligibility Criteria

This meta-analysis was limited to randomized controlled trials (RCTs) among adult patients (age >18 years) who underwent surgery and were allocated to either a perioperative opioid education intervention or conventional education. For the purpose of this meta-analysis, we considered the perioperative education defined by each trial, which mainly consisted of informative sessions about the risks of opioid dependency and the use of alternatives for pain control. However, the type of perioperative education varied among the studies. We did not restrict our selection criteria to studies in specific regions of the world or reporting outcomes at any specific time interval. We included peer-reviewed original articles.

Intervention

Any perioperative opioid education strategy (ie, verbal, written, video, or any combination) was considered as the intervention as long as the description included information about opioid-related adverse drug events (ORADEs), pain modulation, and risks of opioid overuse. We included studies in which the intervention was conducted during hospitalization either before or after surgery.

Outcomes

The primary outcome in this meta-analysis was the number of opioid pills consumed within 15 days, 6 weeks, and 3 months after surgery. Secondary outcomes included rate of opioid cessation, number of patients who needed opioid refills, and appropriate disposal of unused opioids (defined as any of the proper Food and Drug Administration [FDA]–approved disposal methods including dropoff at a drug takeback site such as hospitals, pharmacies, and police stations).^¹⁴

Methodological Quality and Quality of Evidence

Methodological quality assessment was performed using the Cochrane Risk of Bias tool for randomized studies. Each study was assessed based on the 7 domains of potential bias (random sequence generation, allocation concealment, blinding of intervention, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias). The quality of the evidence provided in this meta-analysis was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, as previously reported.^¹⁵ The GRADE recommendations were ranked based on the quality and level certainty (ie, risk of bias, inconsistency, indirectness, and imprecision) of the available evidence.

Statistical Analysis

The data were initially tabulated and represented using descriptive statistics. An exploratory qualitative analysis was conducted to describe the characteristics of the studies included in this meta-analysis. The risk of opioid cessation was extracted as a dichotomous variable (present or absent) and compared using odds ratios (ORs) with their respective 95% confidence intervals (CIs). We used forest plots to illustrate the estimations and overall effect sizes with pooled OR represented as a solid diamond at the bottom of the forest plot. Outcomes presented as continuous variables (eg, number of opioid pills) were compared using weighted mean difference (WMD). In the cases of publication of median values with their ranges, we converted these measures into mean and standard deviations (SDs) using the method by Wan et al.^¹⁶ In the cases of publication of 95% CI of mean values, we calculated the SD using the formula $\sqrt{n} * \frac{(upper - lower limits of 95 % CI)}{3.92} .$ Predetermined subgroup analyses were performed based on the material used for education (video, written, or both). Interaction statistics between the subgroups were calculated to validate any potential difference in the results. Sensitivity analysis was performed based on overall study quality (high or moderate versus low) as determined by quality of evidence assessment. We also used the leave-one-out strategy to assess the consistency of our results. Heterogeneity (I²) was assessed with the correspondent χ² test (I² < 50% and I² > 50% were considered insignificant and significant heterogeneity, respectively). Publication bias was calculated using the Begg and Egger test.^¹⁵ Funnel plots were constructed to represent any tendency for publishing in favor of positive effect. Significant publication bias was considered when there was asymmetry in the funnel plot, and a statistically significant bias coefficient was noted according to the Egger test.^¹⁵P values <0.05 were considered as statistically significant in all statistical analyses. All analyses were performed using a random-effect model (DerSimonian & Laird method) given the high clinical heterogeneity.^¹⁷ All statistics were performed using Stata version 14.0 (Stata, College Station, TX).

RESULTS

Study Characteristics

An initial search yielded 412 articles. After excluding duplications, we screened a total of 289 titles and abstracts. A total of 271 articles were excluded due to the lack of education intervention or the assessment of education interventions in nonsurgical patients. Two additional studies were excluded due to lack of randomization. Ultimately, 16 full-text articles were reviewed, of which 1 additional study was included after cross-checking references and 5 studies were excluded as they did not assess opioid consumption patterns after hospital discharge. In total, 11 RCTs fulfilled the inclusion criteria, which comprised 1604 patients (804 received opioid education, while 800 received standard care).^{^10–14}^,^{^17–22} Seven trials were conducted in orthopedic surgery, 2 in breast surgery, 1 in urogynecology, and 1 in obstetrical surgery (cesarean section). Five trials followed patients until 15 days after surgery, 6 trials reported information for 6 weeks after surgery, and 3 followed patients until 3 months (Table 1). All trials started the educational intervention preoperatively, and 5 trials also complemented the intervention with discharge education. Figure 1 shows the PRISMA flowchart of trial selection.

Outcomes

Opioid Pill Consumption

Six trials reported information regarding opioid pills consumption at 15 days. Three trials showed a statistically significant reduction of opioid pills consumption in the group that received perioperative education. Meta-analysis revealed a statistically significant reduction in opioid pills consumed within the first 15 days that favored perioperative opioid education interventions (WMD, −3.39 pills; 95% CI, −6.40 to −0.37; P = .03; I² = 69%; Figure 2). There was not enough information to assess the effects on the reduction of opioid pills at 6 weeks and 3 months. In subgroup analysis by type of surgery, opioid consumption at 15 days was still reduced when using perioperative opioid education among patients who underwent orthopedic surgery (3 trials; WMD, −5.11 pills; 95% CI, −7.25 to −2.97; P = .001; I² = 0%), but there was no significant reduction in nonorthopedic surgery (3 trials: WMD, −1.12 pills; 95% CI, −5.29 to −3.06; P = .60; I² = 65%) (ie, cesarean, urogynecology, and breast surgeries). Test for interaction was statistically significant (P = .002), meaning that, based on the current evidence, the effect of perioperative opioid education is effectively greater in orthopedic population than in nonorthopedic populations.

Table 1. - Description of the Clinical Trials Included in This Meta-Analysis

Study	Sample size	Intervention	Surgery	Outcomes	Follow-up	Method for observing outcome
Darnall et al,^¹² 2019	I: 36	Video-based instrument of 90 min with information and skills to regulate cognition, emotion, and physiologic hyperarousal related to pain, including relaxation, thought reframing, and behaviors that modulate attention and counteract helplessness about pain	Breast	Opioid cessation	15 d, 6 wk, 3 mo	REDCap survey (Internet) or phone calls
Darnall et al,^¹² 2019	C: 32		Breast	Opioid cessation	15 d, 6 wk, 3 mo	REDCap survey (Internet) or phone calls
Egan et al,^¹⁶ 2020	I: 39	Paper-based instrument divided into 3 sections. It contained information about pain expectations, goals of tolerable pain, risks associated with opioid use, adjunct medications that may be used perioperatively, nonmedication pain control methods, and statements to normalize the pain experience for the patient	Breast	Opioid pills consumed and opioid refills	15 d	Internet survey
Egan et al,^¹⁶ 2020	C: 46		Breast	Opioid pills consumed and opioid refills	15 d	Internet survey
Lam et al,^¹⁷ 2020	I: 84	Video-based education instrument with handouts and in-person instruction about optimal analgesic use	Cesarean	Opioid cessation, opioid pills consumed, and refills	15 d	Phone calls
Lam et al,^¹⁷ 2020	C: 91		Cesarean	Opioid cessation, opioid pills consumed, and refills	15 d	Phone calls
Stepan et al,^¹¹ 2020	I: 93	Webinar and paper-based education discussing information about perioperative pain management, expected pain after surgery, side effects of opioids, tiered system of pain management, and modalities of pain relief	Hand surgery	Opioid pills consumed and opioid refills	15 d	Phone calls
Stepan et al,^¹¹ 2020	C: 97		Hand surgery	Opioid pills consumed and opioid refills	15 d	Phone calls
Syed et al,^¹⁰ 2018	I: 68	Video-based instrument of 2 min containing a handout detailing the risks of narcotic overuse and abuse. In addition, patients received education detailing recommended postoperative opioid usage, side effects, dependence, and addiction.	Rotator cuff repair	Opioid cessation and opioid pills consumed	6 wk, 3 mo	Follow-up visits or phone calls
Syed et al,^¹⁰ 2018	C: 66		Rotator cuff repair	Opioid cessation and opioid pills consumed	6 wk, 3 mo	Follow-up visits or phone calls
Bloom et al,^¹³ 2020	I: 65	Video-based educational instrument on the proper use and dangers of opioids	Rotator cuff repair	Opioid refills	6 wk, 3 mo	Phone calls and electronic records
Bloom et al,^¹³ 2020	C: 65		Rotator cuff repair	Opioid refills	6 wk, 3 mo	Phone calls and electronic records
Nahhas et al,^¹⁴ 2020	I: 183	Paper-based instrument with educational pamphlets plus text messages on proper disposal of unused opioids	Arthroplasty	Opioid cessation and opioid refills	6 wk	Follow-up visits and electronic records
Nahhas et al,^¹⁴ 2020	C: 139		Arthroplasty	Opioid cessation and opioid refills	6 wk	Follow-up visits and electronic records
Sabesan,^¹⁸ et al 2020	I: 25	Paper-based educational materials on alternative pain management protocols, as well as discharge instructions detailing the opioid crisis, postoperative alternative nonopioid medications, and pain management plan. Patients were also counseled verbally by a member of the research team on pain expectations after surgery, nonopioid alternatives to control pain, and over-the-counter analgesics for pain relief.	Shoulder arthroplasty	Opioid cessation	15 d	Phone calls and follow-up visits
Sabesan,^¹⁸ et al 2020	C: 25		Shoulder arthroplasty	Opioid cessation	15 d	Phone calls and follow-up visits
Ilyas et al,^²⁰ 2021	I: 107	Video-based educational instrument about the nature of opioids, statistics on the “Opioid Epidemic” in America, how to safely consume opioids, nonopioid pain management strategies, and how to avoid opioid dependence	Shoulder, elbow, and wrist surgeries	Opioid pills and refills	15 d	Follow-up visits and phone calls
Ilyas et al,^²⁰ 2021	C: 130		Shoulder, elbow, and wrist surgeries	Opioid pills and refills	15 d	Follow-up visits and phone calls
Singh et al,^¹⁹ 2018	I: 39	Written instructions outlining postoperative pain expectations and recommendations for opioid medication usage and disposal	Foot and ankle surgery	Opioid refills	6 wk	Phone calls
Singh et al,^¹⁹ 2018	C: 39		Foot and ankle surgery	Opioid refills	6 wk	Phone calls
Buono et al,^²¹ 2021	I: 65	Paper-based educational pamphlets containing information regarding side effects and risks of opioid consumption, safe storage patterns of opioid tablets, and recommendations regarding postoperative opioid consumption	Reconstructive pelvic surgery	Opioid pills, refills, and disposal	15 d, 6 wk	Follow-up visits and phone calls
Buono et al,^²¹ 2021	C: 70		Reconstructive pelvic surgery	Opioid pills, refills, and disposal	15 d, 6 wk	Follow-up visits and phone calls

Abbreviations: C, control; I, intervention; REDCap, Real Time Electronic Digitally Controlled Analyzer Processor.

Subgroup analysis by type of educational intervention showed a statistical reduction of opioid consumption at 15 days when implementing multimedia/audiovisual strategies (4 trials: WMD, −4.05 pills; 95% CI, −6.59 to −1.50; P = .002; I² = 45%), but there was no apparent decrease when using only paper-based strategies (2 trials: WMD, −2.31 pills; 95% CI, −12.21 to 7.59; P = .65; I² = 80%). Test for interaction was also statistically significant (P = .012).

Opioid Cessation

Six trials reported information about opioid cessation. Three trials included information at 15 days, 3 at 6 weeks, and 3 at 3 months after surgery. Perioperative opioid education did not have significant impact on opioid cessation at 15 days (OR, 0.25; 95% CI, 0.04–1.56; P = .14; I²=83%), 6 weeks (OR, 0.69; 95% CI, 0.46–1.06; P = .10; I² = 0%), or 3 months (OR, 0.59; 95% CI, 0.17–2.01; P = .10; I² = 55%) after surgery. Forest plots for this outcome are shown in Figure 3. It was not possible to conduct subgroup analysis for this outcome due to the low number of trials.

Opioid Refills

The number of patients who required opioid refills was reported in 4 trials at 15 days and 6 weeks. There was no difference in opioid refills between both groups at 15 days (OR, 0.57; 95% CI, 0.28–1.15; P = .12; I² = 20%; Figure 4) and 6 weeks (OR, 1.08; 95% CI, 0.59–1.98; P = .80; I² = 37%; Figure 4). There was not enough information for opioid refills at 3 months. It was not possible to conduct subgroup analysis for this outcome due to the low number of trials.

Appropriate Disposal of Unused Opioid Pills

Two out of 3 trials showed a statistically significant improvement in the disposal of unused opioids. After pooling all 3 trials, there was no statistically significant difference in the rate of appropriate disposal of unused opioids between both groups (OR, 1.99; 95% CI, 0.66–6.00; P = .22; I² = 71%; Supplemental Digital Content, Figure 2, https://links.lww.com/AA/D578).

Methodological Quality Assessment

The assessment of study quality and the risk for bias are shown in Supplemental Digital Content, Figure 1, https://links.lww.com/AA/D578. Overall, 6 studies were classified as low risk, and 3 studies as moderate risk of bias. The sensitivity analysis demonstrated the consistency of our results (Supplemental Digital Content, Figure 3, https://links.lww.com/AA/D578).

GRADE Ranking Recommendations

Based on the current evidence and level of certainty (Table 2), the effectiveness of perioperative education on the reduction of opioid pills consumption after hospital discharge is moderate. There was low recommendation for the outcomes: opioid cessation and need for refills, and very low for appropriate disposal of unused opioid pills.

Publication Bias

We were able to draw an Egger plot for opioid pills consumption (Supplemental Digital Content, Figure 4, https://links.lww.com/AA/D578), which did not show significant publication bias (−2.06, P = .37). It was not possible to construct funnel plots for the rest outcomes due to the low number of studies.

DISCUSSION

In this meta-analysis, our group summarized the most updated RCTs evaluating the effectiveness of perioperative opioid education interventions on opioid consumption over time, cessation, and refills after hospital discharge. Our results showed a statistically significant impact of opioid education interventions on the reduction of postoperative opioid pills consumption at 15 days postsurgery. However, there was no reduction in the risk of opioid cessation and requirement of opioid refills when implementing opioid education interventions.

Table 2. - GRADE Recommendations and Summary of the Evidence

Studies	Risk of bias	Inconsistency	Indirectness	Imprecision	Sample size		Effect	Certainty
Studies	Risk of bias	Inconsistency	Indirectness	Imprecision	Opioid education	Control	Relative (95% CI)	Certainty
Opioid pill consumption (follow-up: median 15 d; assessed with: number of pills)
6	Not serious	Serious	Not serious	Not serious	518	570	WMD, −3.39 pills lower (−6.40 lower to −0.37 lower)	⊕⊕⊕○
6	Not serious	Serious	Not serious	Not serious	518	570	WMD, −3.39 pills lower (−6.40 lower to −0.37 lower)	MODERATE
Opioid cessation (follow-up: median 15 d; assessed with: patients who ceased opioids)
3	Not serious	Serious	Not serious	Serious	23/145 (15.9%)	50/148 (33.8%)	OR, 0.25 (95% CI, 0.04–1.56)	⊕⊕○○
3	Not serious	Serious	Not serious	Serious	23/145 (15.9%)	50/148 (33.8%)	OR, 0.25 (95% CI, 0.04–1.56)	LOW
Opioid cessation (follow-up: median 6 wk; assessed with: patients who ceased opioids)
3	Not serious	Serious	Not serious	Serious	48/219 (21.9%)	47/171 (27.5%)	OR, 0.69 (95% CI, 0.46–1.06)	⊕⊕○○
3	Not serious	Serious	Not serious	Serious	48/219 (21.9%)	47/171 (27.5%)	OR, 0.69 (95% CI, 0.46–1.06)	LOW
Opioid cessation (follow-up: median 3 mo; assessed with: patients who ceased opioids)
3	Not serious	Serious	Not serious	Serious	9/101 (8.9%)	8/97 (8.2%)	OR, 0.59 (95% CI, 0.17–2.01)	⊕⊕○○
3	Not serious	Serious	Not serious	Serious	9/101 (8.9%)	8/97 (8.2%)	OR, 0.59 (95% CI, 0.17–2.01)	LOW
Opioid refills (follow-up: 15 d; assessed with: need for opioid refills)
4	Not serious	Serious	Not serious	Serious	18/342 (5.3%)	35/374 (9.4%)	OR, 0.57 (95% CI, 0.28–1.15)	⊕⊕○○
4	Not serious	Serious	Not serious	Serious	18/342 (5.3%)	35/374 (9.4%)	OR, 0.57 (95% CI, 0.28–1.15)	LOW
Opioid refills (follow-up: 6 wk; assessed with: need for opioid refills)
4	Not serious	Serious	Not serious	Serious	116/352 (32.9%)	90/301 (29.9%)	OR, 1.08 (95% CI, 0.59–1.98)	⊕⊕○○
4	Not serious	Serious	Not serious	Serious	116/352 (32.9%)	90/301 (29.9%)	OR, 1.08 (95% CI, 0.59–1.98)	LOW
Appropriate disposal of unused opioids (assessed with: patients who disposed unused opioids appropriately)
4	Not serious	Serious	Not serious	Very serious	80/241 (33.2%)	26/206 (12.6%)	OR, 2.61 (95% CI, 0.84–8.04)	⊕○○○
4	Not serious	Serious	Not serious	Very serious	80/241 (33.2%)	26/206 (12.6%)	OR, 2.61 (95% CI, 0.84–8.04)	VERY LOW

Abbreviations: CI, confidence interval; GRADE, Grading of Recommendations, Assessment, Development, and Evaluation; OR, odds ratio; WMD, weighted mean difference.

Perioperative opioid education has become increasingly more relevant over the last few decades. The role of perioperative education interventions has been reported widely in the literature.^¹⁹ There is evidence that patient education initiatives improve postoperative patient satisfaction^²³ and increase the level of knowledge on pain management among surgical patients.^²⁴ Furthermore, simple interventions such as preoperative pamphlets or nursing education may reduce acute pain after surgery and improve functional outcomes.^¹⁹^,^²⁵ The long-term benefits remain unknown given the controversial results among the studies assessing the effectiveness of such interventions.^²⁶

Our findings are consistent with large observational studies. Although this meta-analysis demonstrated a statistically significant reduction of 3–4 pills at 15 days when implementing perioperative opioid education, this effect is not clinically significant. Individual cohort studies suggest that the presence of opioid education initiatives may be associated with a decrease in postdischarge opioid prescribing while improving disposal after surgery.^²⁴^,^²⁷ Hite et al^²⁸ implemented an opioid education initiative over a 1-year period and demonstrated the feasibility of this specific type of intervention without compromising postoperative pain control. Other observational studies have shown improved awareness about the correct disposal of opioid medications.^²⁹^,^³⁰

The effectiveness of opioid education interventions in decreasing postoperative opioid consumption could be explained by increased patient engagement and a better understanding regarding the role of nonopioid analgesic modalities, pain expectations, and the potential risk of opioid-related side effects. Based on Table 1, these 3 were the most common topics included in the education interventions and seem to contribute to the reduction in opioid consumption. As noted in this meta-analysis, there is a wide variety of educational strategies. Interestingly, opioid pills consumption was reduced when implementing audiovisual/multimedia methods but not when using only paper-based strategies, which suggest that patient engagement may improve when using more interactive educational initiatives. Other recent studies have also suggested preoperative behavioral modalities for education.^³¹ My Surgical Success is a digital behavioral intervention that has been applied among patients undergoing breast surgery and has shown positive impact on the risk of opioid cessation and patient satisfaction.^¹² Other common types of institutional strategies involve educating clinicians regarding prescribing behavior (ie, procedure-specific opioid-prescribing guidelines, and departmental policy.^{^32–34} Those 2 interventions should complement patient education to obtain significant benefits in opioid consumption and greater level of knowledge on multimodal-pain control.^³⁵ For instance, Meisenberg et al^³⁶ and Berkman et al^³⁷ were able to reduce opioid prescriptions after developing a multimodal intervention involving prescriber (ie, surgeons, nurses, and anesthesiologists) and patient education.

Future studies may help identify which patients will benefit most from educational interventions and what additional benefits there are to education. Identification of patients who are at higher risk for long-term opioid use may theoretically allow for preoperative interventions to avoid postoperative chronic opioid use.^⁵ However, further evidence is needed whether perioperative opioid education among chronic opioid users may have the higher impact than that in opioid-naïve population. In this meta-analysis, only 2 of the trials conducted subgroup analysis in chronic opioid users, demonstrating significantly higher benefit in this particular patient population,^¹⁰^,^¹¹ thus suggesting that patient selection may be key to demonstrate superior results from opioid education.

In addition to the reduction of opioid pills evidenced in this study, it is possible that opioid education interventions could bring further benefits in terms of lower risk of opioid-related adverse events, drug dependency, and opioid misuse. However, these factors have not been studied as secondary outcomes after opioid education interventions. Among other targeted end points that should be considered include cost outcomes of readmissions and other financial costs related to drug addiction and rehabilitation. Functional outcomes could also be affected by perioperative education strategies, since it is known that rehabilitation programs, counseling, and behavioral therapy facilitate patients returning to work.^³⁸^,^³⁹

There are important barriers for the implementation of patient education interventions. Coughlin et al^⁴⁰ performed a qualitative study using semistructured interviews among essential stakeholders and identified 12 potential implementation barriers including time and resource constraints, the type of modality of educational material (design quality and packaging), and prescribers’ concerns for patient satisfaction scores (external policy and incentives). It is therefore recommended that institutions implement strategies to achieve best outcomes from perioperative education interventions.

This meta-analysis has a number of limitations. First, the low number of studies in the analyses for each outcome may increase the likelihood of type I error in our findings, though there was no evidence of publication bias in our primary outcome. Second, it was not possible to analyze pain scores after hospital discharge due to the different presentation of the results between the trials. Third, currently, there is not a validated opioid educational intervention; therefore, this meta-analysis had significant clinical heterogeneity in the modalities used for the educational interventions (paper-based, video, or both), duration of the educational activity, and the topics in each of them, but the content of all of the interventions was focused on the risks associated with opioid use, pain expectations, and awareness of nonmedication pain control methods. However, most of the studies included in this meta-analysis were performed in orthopedic populations and there was evidence of significant statistical heterogeneity. Fourth, there are external biases that may impact opioids use (law changes, published guidelines, and institutional policies) and were not accounted in the statistical analysis. Fifth, it is not possible to make final recommendations based on our results, as there is not a validated opioid reduction threshold to consider or not perioperative opioid educational initiatives. Finally, there remain many unanswered questions in this topic, such as the optimal timing of education interventions (preoperative versus postoperative), the benefits of such interventions in the context of multimodal analgesia or Enhanced Recovery After Surgery (ERAS) programs, or the effects on patient-reported outcomes (PROs) at long term.

In conclusion, perioperative educational interventions reduce the number of opioid pills consumed at 15 days, but there was no benefit demonstrated in terms of opioid cessation or reduction in opioid refills. Future RCTs should focus on evidence-based educational interventions (ie, multimedia/audiovisual strategies) with strict hom*ogeneity of material to draw a more definitive recommendation. Further evidence is also needed to determine the impact of educational strategies on long-term opioid-related outcomes (ie, misuse and addiction).

ACKNOWLEDGMENTS

Individual-patient data of 2 trials was provided by Dr Kristen Buono (Division of Pelvic Medicine and Reconstructive Surgery, Urogynecology Consultants, Sacramento, CA) and Dr Jeffrey Stepan (Hospital for Special Surgery, New York, NY).

DISCLOSURES

Name: Andres Zorrilla-Vaca, MD.

Contribution: This author helped design the study, write the manuscript, extract the data, perform statistical analysis, interpret the results, and approve the final manuscript.

Conflicts of Interest: None.

Name: Gabriel E. Mena, MD.

Contribution: This author helped write the manuscript, interpret the results, and approve the final manuscript.

Conflicts of Interest: G. E. Mena receives an academic grant from PACIRA Pharmaceuticals.

Name: Pedro T. Ramirez, MD.

Contribution: This author helped write the manuscript, interpret the results, and approve the final manuscript.

Conflicts of Interest: None.

Name: Bradley H. Lee, MD.

Contribution: This author helped write the manuscript, extract the data, interpret the results, and approve the final manuscript.

Conflicts of Interest: None.

Name: Alexandra Sideris, PhD.

Contribution: This author helped write the manuscript, interpret the results, and approve the final manuscript.

Conflicts of Interest: A. Sideris is supported by the C.V. Starr Foundation and serves as a consultant on a cannabinoid research grant funded by Colmbia Cientifica/Colciencias.

Name: Christopher L. Wu, MD.

Contribution: This author helped design the study, write the manuscript, interpret the results, and approve the final manuscript.

Conflicts of Interest: C. L. Wu receives salary support through a contract with the AHRQ (HHSP233201500020I).

This manuscript was handled by: Tong J. Gan, MD.

^GLOSSARY

CI: confidence interval
ERAS: Enhanced Recovery After Surgery
FDA: Food and Drug Administration
GRADE: Grading of Recommendations, Assessment, Development, and Evaluation
OR: odds ratio
ORADEs: opioid-related adverse drug events
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
PROs: patient-reported outcomes
RCT: randomized controlled trials
SD: standard deviation
WMD: weighted mean difference

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Supplemental Digital Content

AA_2021_05_10_ZORRILLAVACA_AA-D-20-02446R3_SDC1.pdf; [PDF] (224 KB)

Corresponding Article

Perioperative Opioid Education Initiatives: Do They Add Value?

Desai, Amruta; Dahan, Albert; Gan, Tong J.

Anesthesia & Analgesia. 134(5):938-939, May 2022.