










































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW  

 

40 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

 
 

Opioid Medication Use and Education Following Sports Medicine 
Procedures: An Evidence-to-Practice Review  
Caitlin S. O’Mara, SCAT, ATC; Michael G. Ward, SCAT, ATC; Zachary K. Winkelmann, PhD, SCAT, ATC 
University of South Carolina, Columbia, SC 

  

 
ABSTRACT 
According to the Centers for Disease Control (CDC), illicit and 
prescription drug overdoses are responsible for 128 deaths 
every day in the United States. In 2018, 70% of all overdose 
related deaths involved opioids. Efforts to minimize the 
opioid epidemic focus on community education, research, 
partnership, and healthcare support. Under the CDC 
guidelines, current practices include monitoring trends of drug 
use and drug related deaths, conducting research to 
recognize areas in need of improvement and to analyze 
effectiveness of current treatments, partner with community 
organizations and healthcare systems that deal firsthand with 
opioid users, and educate the public on drug use, misuse, and 
overdoses. People are commonly uneducated on the proper 
use and disposal of their prescription opioids. Consistent and 
appropriate communication among surgeons and their 
patients can decrease this risk associated with prescription 
drugs. The purpose of this evidence-to-practice review was 
to summarize a systematic review on the current data and 
findings related to postoperative opioid prescribing and 
consumption behaviors after a common sports medicine 
operation. The guiding systematic review explored several 
ways to reduce the risk of patients developing opioid 
dependence and abuse due to physicians overprescribing 
opioids. First, educating each patient about pain 
management during pre- and postoperative phases, how to 
store opioids safely, and how to dispose of opioids properly 
need to be created to help reduce the risk of the patient 
abusing opioids. Secondly, having the prescribing provider 
create an extensive history that reveals any red flags for 
opioid abuse for each patient. Thirdly, the prescribing 
provider should prescribe the lowest dose and shortest 
regimen to limit the number of opioids left over. These 
protocols may help slow the current opioid epidemic. 
 
Key Phrases 
Drug overdose/drug therapy, program evaluation, 
opioid-related disorders/drug therapy, 
naloxone/therapeutic use 
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, 
SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
O’Mara CS, Ward MG,Winkelmann ZK. Opioid 
Medication Use and Education Following Sports 
Medicine Procedures: An Evidence-to-Practice Review. 
Clin Pract Athl Train. 2021;4(2): 40-44. 
https://doi.org/10.31622/2021/0004.2.6.   
 
Submitted: December 15, 2020 Accepted: March 3, 2021. 

 

ORIGINAL REFERENCE 
Sheth U, Mehta M, Huyke F, Terry MA, Tjong 
VK. Opioid Use After Common Sports Medicine 
Procedures: A Systematic Review. Sports 
Health. 2020;12(3):225-233. 
https://doi.org/10.1177/1941738120913
293. 
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 

In the United States, orthopedic surgeons are 

responsible for 7.7% of all prescribed opioids.1 
When investigating the effects of these practices, 
two main factors that are studied are mean 
prescription and consumption values, and 
appropriate disposal procedures. The guiding 
systematic review examines these factors 
following three common procedures: knee, 
shoulder, and hip arthroscopies. With the increase 
in the level of skill and competition in athletics, 
there comes an increased need in medical and 
surgical knowledge. Studies have shown that there 
are close to 2 million knee arthroscopic surgeries 
performed every single year in the United States.2 
The incidence for the other common injuries (hip 
and shoulder) are increasing dramatically as well. 
The drastic increase of these injuries has directly 
impacted the prescribing patterns of orthopedic 
surgeons in the United States. Patients and 
surgeons often assume the use and duration of 
opioid treatment, that the decision to determine 
the extent to which the patient needs an opioid 
prescription, is often overlooked. Regardless of 
how common the surgery is, or how many times the 
specific surgeon has performed the surgery, 
postoperative opioids should be prescribed 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2021/0004.2.6
https://doi.org/10.1177/1941738120913293
https://doi.org/10.1177/1941738120913293


Opioid Medication Use and Education Following Sports Medicine Procedures: An Evidence-to-Practice Review 
 

 

41 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

based on the individual patient and with prior 
research in mind. Supporting research has shown 
that large percentages of prescribed 
postoperative opioids are not consumed and/or 
disposed of properly.3,4 In addition to less 
individualized prescribing patterns, education on 
proper disposal medication was not always 
provided.6 A lack of awareness of proper 
disposal can often lead to the patient stockpiling 
their unused medications. The act of collecting pills 
poses a great risk for future drug abuse or 
suicidal means. These subsequent behaviors 
threatened the health and wellbeing of patients, 
their support systems, and adds to the burden of 
the current drug epidemic in the United States. 
Therefore, the purpose of this evidence to practice 
review was to summarize a systematic review on 
the current data and findings related to 
postoperative opioid prescribing and consumption 
behaviors following three common sports medicine 
procedures. 

SUMMARY OF LITERATURE 

A systematic search was conducted using EMBASE, 
MEDLINE, and PubMed databases. The keywords 
searched included arthroscopy, sports medicine, 
opioids, and other related wording. Inclusion 
criteria consisted of studies containing patients 
experiencing an arthroscopic procedure of the 
knee, hip, or shoulder. Other significant inclusion 
criteria included evaluation of postoperative 
opioid prescribing behaviors and evaluated 
opioid consumption rates.2 Studies also needed 
more than 10 participants and had reports of 
patient-specific data to be accepted. Quality of 
the studies was determined using the 
Methodological Index for Non-Randomized 
Studies. For these studies; the highest possible 
score is a 16. All studies had a score of 10 or 
higher, assigning them high quality. The initial 
search identified 119 studies. After screening, 8 
studies meet the inclusion criteria and were 
deemed eligible. 

SUMMARY OF OUTCOMES 

Five variables were examined in the various 
studies including opioid prescribing practices, 
postoperative opioid consumption, duration of 
opioid use, opioid disposal, and refill rate. During 
statistical analysis, the guiding review’s authors 
referred to the accepted conversion table from 
the Centers for Medicare and Medicaid Services.5 
With the oral morphine milligram equivalent 
conversion factors, the quantity of opioids 
prescribed, used, and leftover were converted to 
milligram morphine equivalents (MMEs) for 
standardized reporting.6 In the studies converting 
opioid prescribing patterns, MMEs are identified 
for arthroscopic procedures of the shoulder, hip, 
and knee.  

FINDINGS AND CLINICAL IMPLICATIONS 

Among 195 patients (3 studies) undergoing the 
shoulder procedure, there was a mean of 610 
MMEs prescribed and 418 MMEs consumed. For 
451 patients (4 studies) undergoing the knee 
procedure, there was a mean of 197 MMEs 
prescribed and 131 MMEs consumed. For 96 
patients (2 studies) undergoing hip procedure, 
there was a mean of 613 MMEs prescribed and 
223 MMEs consumed.2 To summarize these 
findings, the percentage of prescribed opioids 
going unused are: 31% for shoulder procedures, 
34% for knee procedures, and 64% for hip 
procedures. Out of the three surgical procedures, 
30mg tablets of oral codeine were prescribed 
most frequently. The other most frequently 
prescribed opioids were a 5mg tablet of oral 
hydrocodone and a 5mg tablet of oxycodone.6 
Two additional studies (277 patients) focused on 
how frequently post-op patients refill their 
prescription. The studies concluded that 26% of 
these patients asked for a prescription refill 
following their procedure. This review found 
overwhelming evidence that opioids are 
overprescribed for patients that have undergone 
shoulder, knee, and hip arthroscopic surgery 



Opioid Medication Use and Education Following Sports Medicine Procedures: An Evidence-to-Practice Review 
 

 

42 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

despite that evidence has shown that more than 
one third of opioids prescriptions went used and 
more than half of the patients do not take the 
opioids after 3 days following their surgery. Five 
studies (348 patients) looked at opioid disposal 
methods or if the patient had any prior education 
on how to properly dispose of the excess 
prescription. Out of those 348 patients, only 36% 
of patients were given instruction on how to 
dispose of their medications when they no longer 
needed them for pain management.1 

After finding that only 36% of patients were 
given instruction on how to properly dispose of 
their unused medications, there is an increased 
emphasis on developing strategies to better 
inform guidelines for both the doctors and the 
patients.1 An increased focus on better prescribing 
patterns for doctors along with a more consistent 
patient education program are two critical 
components needed to evoke change. One 
strategy that has been suggested is for surgeons 
to prescribe the lowest dosage for the shortest 
duration period.7 Several studies have made 
dosage recommendations on these three specific 
procedures as well as alternate strategies for 
controlling postoperative pain.  

The authors of the guiding systematic review 
discussed the growing risk of the over prescribing 
patterns of opioids and demonstrated that sports 
medicine procedures are no exception. The opioid 
use concerns are not just limited to providers 
prescribing more than needed, but also to the lack 
of education given to their patients. 
Overprescribing and improper disposal methods 
leads to more opioid medications in the hands of 
people they don’t belong, in turn becoming a 
contributing factor to the opioid epidemic. This 
heightens the need for athletic trainers and other 
healthcare providers to be aware of signs and 
symptoms of opioid abuse. If the problem can be 
identified early on, there is more time for an 
appropriate intervention or referral to be made. 
This additional time can be the difference 

between a healthy post-operative experience 
and one with long term complications. The guiding 
systematic review found overwhelming evidence 
that opioids were overprescribed to patients that 
have undergone shoulder, knee, and hip 
arthroscopic surgery. Even with doctors 
overprescribing opioids, only 36% of the surgical 
patients were educated on how to dispose of the 
medication(s) when they were no longer needed 
for pain management.1 These statistics are not 
unique to these three surgeries. Over prescription 
is also seen in foot, ankle, and even upper 
extremity surgical literature.8  

CLINICAL BOTTOM LINE 

Due to the ongoing battle with the opioid 
epidemic, which includes misuse and abuse of 
opioids, focus has been shifted on creating safer 
prescription practices. An initial in-depth 
preoperative medical history can aid the clinician 
with a more appropriate pain management 
consideration. Each patient would be assessed for 
not only past opioid use but other drug 
dependencies as well.1 In addition, each patient 
would be educated using handouts about the 
expectations of pain throughout the preoperative 
and postoperative phases as well as storing and 
disposing of the medication. According to one 
systematic review, 5% of the patients were 
educated on how to dispose of medication 
properly, 3 out of 4 patients stored the 
medication in an unlocked location, and less than 
30% planned to or disposed of any unused 
opioids. Of that, less than 10% disposed of the 
opioids by returning to the pharmacy or flushing 
down the toilet.8,9 The best option for disposing of 
unused medications is to return them to an official 
take back location. Take back locations can 
include pharmacies, police stations, or other 
approved sites. The Drug Enforcement Agency 
website allows individuals to enter their zip code 
and find locations within their area that allow 
medication take backs. The DEA website also has 
a “flush list” of what medications are safe to be 



Opioid Medication Use and Education Following Sports Medicine Procedures: An Evidence-to-Practice Review 
 

 

43 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

flushed down the toilet. If the medication is not 
listed on the flush list, the only disposal method is 
to return to a take back location. Take back 
locations are the safest option because it 
minimizes the risk that someone within the home 
will get a hold of the medication. It also eliminates 
the risk of a drug contaminating the water if it is 
flushed down the toilet. If the medication is not on 
the flush list and there are no take back locations 
in the area, medications can be disposed of in the 
trash. The FDA suggests mixing the medication with 
a substance like cat litter, dirt, or food waste in a 
sealed plastic bag before placing it in the 
garbage.10 All personal information should be 
scratched off or removed from the prescription 
bottles as well before disposal.10 Another review 
suggested method to limit over prescription is for 
providers to administer other analgesics via 
different intake methods. Several studies within 
the review have shown decreased opioid use after 
surgery on patients treated with multiple 
analgesics during the perioperative phase.7,11 The 
guiding systematic review determined there was 
evidence of a correlation of risk factors that 
correlates with long-term opioid use such as 
suicide, other drug dependency, mood disorders, 
and chronic pain. 

Despite not having control of postoperative 
prescriptions, athletic trainers can be a valuable 
resource for patients to help them understand their 
procedure and prescriptions. Athletic trainers can 
be an advocate for patients to help facilitate 
proper use and ensure clarity of use through 
discussions with the prescribing provider and 
members of the sports medicine team. Ensuring 
that their patient is aware of proper consumption 
and disposal is an easy task that can prevent 
addiction or abuse in the future. The providing 
prescribers can implement this into practice by 
establishing communication with a patient 
throughout the entirety of their surgical process. 
Early and consistent communication among the 
orthopedic surgeon, athletic trainer, and the 
patient can mitigate the risk of opioid addiction. 

Athletic trainers are in a unique position to help 
educate patients on how to properly consume, 
store, and dispose of their opioids. Athletic 
trainers can also work with their collaborating 
physician to develop a plan to avoid post-
operative opioid abuse and misuse. 

REFERENCES 

1. Sheth U, Mehta M, Huyke F, Terry MA, Tjong 
VK. Opioid Use After Common Sports 
Medicine Procedures: A Systematic Review. 
Sports Health. 2020;12(3):225-233. 
https://doi.org/10.1177/1941738120913
293.  

2. Siemieniuk RAC, Harris IA, Agoritsas T, et al. 
Arthroscopic surgery for degenerative knee 
arthritis and meniscal tears: a clinical practice 
guideline. BMJ. 2017;357:j1982. 
https://doi.org/10.1136/bmj.j1982.  

3. Ellis TA, 2nd, Hammoud H, Dela Merced P, et 
al. Multimodal Clinical Pathway With 
Adductor Canal Block Decreases Hospital 
Length of Stay, Improves Pain Control, and 
Reduces Opioid Consumption in Total Knee 
Arthroplasty Patients: A Retrospective Review. 
J Arthroplasty. 2018;33(8):2440-2448. 
https://doi.org/10.1016/j.arth.2018.03.05
3.  

4. Sabatino MJ, Kunkel ST, Ramkumar DB, 
Keeney BJ, Jevsevar DS. Excess Opioid 
Medication and Variation in Prescribing 
Patterns Following Common Orthopaedic 
Procedures. J Bone Joint Surg Am. 
2018;100(3):180-188. 
https://doi.org/10.2106/jbjs.17.00672.  

5. Centers for Disease Control and Prevention. 
Analyzing opioid prescription data and oral 
morphine milligram equivalents (MME). 
https://www.cdc.gov/drugoverdose/resourc
es/data.html. Published October 9, 2020. 

6. Centers for Disease Control and Prevention. 
Understanding the epidemic. 
https://www.cdc.gov/drugoverdose/epidem
ic/index.html. Published 2020, March 19. 
Accessed. 

7. Labrum JT, Ilyas AM. The opioid epidemic: 
Postoperative pain management strategies in 
orthopaedics. JBJS Rev. 2017;5(8):e14. 
https://doi.org/10.2106/jbjs.rvw.16.00124.  

https://doi.org/10.1177/1941738120913293
https://doi.org/10.1177/1941738120913293
https://doi.org/10.1136/bmj.j1982
https://doi.org/10.1016/j.arth.2018.03.053
https://doi.org/10.1016/j.arth.2018.03.053
https://doi.org/10.2106/jbjs.17.00672
https://www.cdc.gov/drugoverdose/resources/data.html
https://www.cdc.gov/drugoverdose/resources/data.html
https://www.cdc.gov/drugoverdose/epidemic/index.html
https://www.cdc.gov/drugoverdose/epidemic/index.html
https://doi.org/10.2106/jbjs.rvw.16.00124


Opioid Medication Use and Education Following Sports Medicine Procedures: An Evidence-to-Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

8. Merrill HM, Dean DM, Mottla JL, Neufeld SK, 
Cuttica DJ, Buchanan MM. Opioid 
Consumption Following Foot and Ankle 
Surgery. Foot Ankle Int. 2018;39(6):649-
656. 
https://doi.org/10.1177/1071100718757
527.  

9. Bicket MC, Long JJ, Pronovost PJ, Alexander 
GC, Wu CL. Prescription Opioid Analgesics 
Commonly Unused After Surgery: A 
Systematic Review. JAMA Surg. 
2017;152(11):1066-1071. 
https://doi.org/10.1001/jamasurg.2017.08
31.  

10. U.S. Food and Drug Administration. How to 
safely dispose of unused or expired medicine. 
https://www.fda.gov/drugs/safe-disposal-
medicines/disposal-unused-medicines-what-
you-should-know. Published September 25, 
2020. 

11. Elkassabany NM, Wang A, Ochroch J, 
Mattera M, Liu J, Kuntz A. Improved Quality 
of Recovery from Ambulatory Shoulder 
Surgery After Implementation of a 
Multimodal Perioperative Pain Management 
Protocol. Pain Med. 2019;20(5):1012-1019. 
https://doi.org/10.1093/pm/pny152.  

 

  

 

 

 

https://doi.org/10.1177/1071100718757527
https://doi.org/10.1177/1071100718757527
https://doi.org/10.1001/jamasurg.2017.0831
https://doi.org/10.1001/jamasurg.2017.0831
https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know
https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know
https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know
https://doi.org/10.1093/pm/pny152

	ABSTRACT

