Opioids in Sports Medicine

By: Niraj V. Kalore, M.D.

The Unresolved Opioid Crisis

As per data from the Centers for Disease Control and Prevention, drug overdose deaths in the U.S. increased by 29.4% from 70,630 in 2019 to 92,183 in 2020. Except for South Dakota and New Hampshire, every state has had an increase in deaths due to drug overdose (Figure 1). This indicates that the opioid crisis in the U.S. is an unresolved problem, despite recent government regulations requiring electronic prescribing and prescription limits.

Figure 1: National Center for Health Statistics Data Analysis on July 4, 2021.

Athletes and Commonly Used Opioids

An estimated 8.6 million sports injuries occur each year¹. Athletes have a strong desire and significant social and/or economic pressure to “play through the pain,” driving them to seek out opioid pain medications to continue playing without properly recovering. This starts the dangerous cycle of “play-pain-opioid-play.” Additionally, these injured athletes are at a higher risk for serious injuries that may require surgery. Using opioid pain medications for postoperative pain control and unsupervised access to leftover prescription pills further aggravate the problem. Prescription opioids’ high cost on the black market then drives athletes to illicit opioids like heroin, which have a significantly increased risk of addiction, accidental overdose and death. This downward spiral from injury to illicit drug use is accelerated in professional athletes due to the intense pressure of a short career and the need to maximize income through continued sports participation.

According to the National Council on Alcoholism and Drug Dependence, 12% of male athletes and 8% of female athletes used prescription opioids in the 12-month period studied. A recent systematic review from Ekhtiari et al. indicated that the rate of opioid use over an NFL career is 52%, while the lifetime opioid use rates in high school athletes are 28%-46%.² Risk factors associated with opioid use included race (particularly Caucasians), contact sports (hockey, football, wrestling), postretirement unemployment and undiagnosed concussion.

Athletes and Overprescribed Opioids

Orthopaedic Surgeons specializing in sports medicine commonly prescribe opioids for postoperative pain control, while occasionally prescribing opioids for serious injuries like fractures or dislocations. A study by Brummett et al. demonstrated that nearly 7% of patients that are prescribed an opioid for minor or major surgery will go on to long-term use or abuse.³ Prescribing more opioids than what’s used results in leftovers that increase the possibility of misuse. A recent study by Sheth et al. found that Orthopaedic Surgeons prescribed 31%, 34% and 64% more opioids following arthroscopy for shoulder, knee and hip, respectively.⁴ Considering that arthroscopic surgeries for the shoulder, knee and hip in the U.S. annually are 2 million, 1 million and 70,000 respectively, Orthopaedic Surgeons are responsible for a staggering number of leftover prescription opioids. (Table 1).

Table 1: The annual volume of hip, knee and shoulder arthroscopy procedures in the U.S. with the mean MME prescribed and utilized.

How Orthopaedic Surgeons Can Help With the Opioid Crisis

Screening for Athletes’ Opioid Usage

Orthopaedic Surgeons must have a high index of suspicion for opioid use and misuse among athletes. The early stages of abuse see nausea and/or vomiting, but diminish as the athlete develops tolerance for the drug. Constipation is not uncommon but may not be reported. One of the most significant indications of a possible opioid addiction is an athlete’s decrease in academic/athletic performance or a lack of interest in their sport. If an Orthopaedic Surgeon notices these warning signs, they should educate the athlete on opioid misuse in a nonjudgmental manner. This could be a difficult conversation as the athlete is unlikely to reveal any opioid misuse. It is important to initiate a referral to the appropriate professional and follow up with the athlete.

Using Nonopioid Pain Control Strategies

Orthopaedic Surgeons should use multipronged, multidisciplinary opioid-sparing pain control strategies as an integral part of injury management. The International Olympic Committee consensus statement on pain management in elite athletes provides guidance on pain management for athletic injuries⁷. Injury management should include ice, bracing, taping, strength/conditioning, injury prevention and physical therapy with modalities. Pharmacological treatment suitable for acute pain and same-day return to sports include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and topical analgesics. Intramuscular ketorolac and local anesthetic injections should be reserved for moderate-to-severe acute pain and same-day return to sports. For more serious injuries that cause extreme pain (in addition to other aspects of injury management), opioids may be prescribed in the lowest possible dose without exceeding three days. The treatment approach for managing subacute and chronic pain in athletes should be multidisciplinary, shifting from relieving pain to improving function and preventing chronic/associated disability.

A similar multimodal pain management approach after surgery provides excellent pain control and patient satisfaction with significantly lower opioid usage⁸. Regional analgesia is a powerful tool for perioperative pain control and should be liberally used. Regional analgesia with nerve blocks, such as interscalene nerve block for shoulder, femoral/adductor canal block for knee and fascia iliaca compartment block for hip, are safe, have a high efficacy for pain control and help reduce opioid consumption along with its associated side effects.

Educating Athletes on Opioid Use

Orthopaedic Surgeons are encouraged to warn their athlete patients about the risk of addiction with overreliance on opioids for postoperative pain control. Athletes often cite the adverse effects from using NSAIDs that have been publicized but seem to underestimate the risk of opioid dependence. Education on the safe use of NSAIDs and Tylenol, as well as allaying anxiety over their side effects, would help reduce the athlete’s overreliance on opioids for pain control. Additionally, Orthopaedic Surgeons should utilize preoperative visits to set correct expectations for postoperative pain control. Athletes who expect pain-free surgery are more likely to overmedicate or rely on opioids. Opioid disposal is a neglected aspect of the opioid crisis, with only 33% of athletes getting any education about disposing leftover opioid pills. Orthopaedic Surgeons should check with athletes for leftover opioids during postoperative visits and counsel them for proper disposal options, such as a prescription drug drop-off or home disposal kit.

Prescribing Opioids Responsibly

When suitable, opioids should be prescribed in the lowest dose for the shortest duration, in combination with other pain control strategies. When prescribing opioids to adolescents, Orthopaedic Surgeons should educate parents on the danger of unsupervised access to prescription opioids and have them take charge of any opioids prescribed to their children. The surgeon should be aware of the mean MMEs athletes use for commonly performed procedures. This should be used as the basis for deciding the number of pain pills that are prescribed. Additionally, in accordance with current regulations, a prescription-monitoring program report should be checked, and opioid scripts should be limited to three-seven days at a time. As responsible prescribers, Orthopaedic Surgeons should comply with these prescription limits as well as electronic prescribing. Mandatory prescription limits typically result in a significant reduction in opioid utilization after orthopaedic surgery.⁹

Conclusion

The opioid crisis is currently out of control. Athletes of all levels with sports injuries are vulnerable to opioid use and misuse. There is a high rate of opioid use in professional athletes as well as high school athletes. Orthopaedic Surgeons who specialize in sports medicine should be vigilant in monitoring athletes for signs of problematic opioid use. Sports injury management should involve a multidisciplinary approach in addition to pharmacologic pain control, which should rely on blocking the pain pathway at multiple levels. Athletes would benefit the most from education on the risks of opioid use and its proper disposal.

References

1. Sheu, Y., Chen, L.H., Hedegaard, H. “Sports- and Recreation-Related Injury Episodes in the United States: 2011-2014.” National Health Statistics Report. 2016;(99):1-12
2. Ekhtiari, S., Yusuf, I., AlMakadma, Y., MacDonald, A., Leroux, T., Khan, M. “Opioid Use in Athletes: A Systematic Review.” Sports Health. 2020;12(6):534-539.
3. Brummett, C.M., Waljee, J.F., Goesling, J. “New Persistent Opioid Use After Minor and Major Surgical Procedures in U.S. Adults.” Journal of the American Medical Association (JAMA) Surgery. 2017;152.
4. Sheth, U., Mehta, M., Huyke, F., Terry, M.A., Tjong, V.K. “Opioid Use After Common Sports Medicine Procedures: A Systematic Review.” Sports Health. 2020;12(3):225-233.
5. Howard. “Trends in the Use of Knee Arthroscopy in Adults.” Journal of the American Medical Association (JAMA) Internal Medicine. 2018;178(11):1557-1558.
6. Sing, D.C., Feeley, B.T., Tay, B., Vail, T.P., Zhang, A.L. “Age-Related Trends in Hip Arthroscopy: A Large Cross-Sectional Analysis.” Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2015;31(12):2307-13.e2.
7. Hainline, B., Derman, W., Vernec, A., et al. “International Olympic Committee Consensus Statement on Pain Management in Elite Athletes.” British Journal of Sports Medicine. 2017;51:1245-1258.
8. Moutzouros, V., Jildeh, T.R., Khalil, L.S., Schwartz, K., Hasan, L., Matar, R.N., Okoroha, K.R. “A Multimodal Protocol to Diminish Pain Following Common Orthopedic Sports Procedures: Can We Eliminate Postoperative Opioids?” Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2020;36(8):2249-2257.
9. Reid, D.B.C., Shah, K.N., Shapiro, B.H., Ruddell, J.H., Akelman, E., Daniels, A.H. “Mandatory Prescription Limits and Opioid Utilization Following Orthopaedic Surgery.” Journal of Bone and Joint Surgery – American Volume. 2019;101(10):e43.