Meta-analysis shows preoperative COX-2 inhibitors and gabapentin reduce opioid use after arthroscopic surgery

BACKGROUND: Orthopaedic surgeons frequently overprescribe opioids after arthroscopic surgery. Previous research has shown reductions in postoperative opioid consumption and pain scores with multimodal nonopioid analgesics. However, the clinical effect of preoperative analgesic strategies has not been fully uncovered. PURPOSE: To assess the outcomes of arthroscopic surgery associated with preoperative treatment with nonopioid medications. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 1. METHODS: Three online databases (PubMed, MEDLINE, Embase) were searched on December 12, 2024, to identify randomized controlled trials investigating the effect of preoperative intervention on pain management following arthroscopic surgery. Extracted data included patient demographics, surgery type, analgesic protocols (ie, type, dosing, timing), adverse effects, postoperative opioid consumption, and pain scores. Postoperative opioid consumption was standardized and converted to oral morphine equivalents. Pain scores were assessed using the visual analog scale (VAS). Weighted means and meta-analyses were conducted to compare postoperative outcomes. Subgroup analyses were performed by analgesic class (COX-2 inhibitors, gabapentin) and surgery type. The quality of studies was assessed with the Risk of Bias 2 tool. RESULTS: A total of 22 studies were included in this review. The overall pooled mean reduction in postoperative opioid consumption with any preoperative medication type was 4.3 mg of oral morphine equivalents (95% CI, -6.1 to -2.5; < .001; = 96%) at 24 hours. The pooled mean reduction associated with preoperative COX-2 administration and gabapentin was 4.2 mg (95% CI, -7.9 to -0.5; = .03; = 93%) and 6.3 mg (95% CI, -9.6 to -3.0; < .001; = 90%) at 24 hours, respectively. Preoperative COX-2 inhibitors also yielded a statistically significant VAS pain reduction of 0.3 cm (95% CI, -0.5 to -0.02; = .04). Patients undergoing anterior cruciate ligament reconstruction had higher postoperative opioid consumption as compared with general knee or shoulder arthroscopies. CONCLUSION: This systematic review demonstrated that preoperative treatment with nonopioid medications, particularly COX-2 inhibitors and gabapentin, is associated with statistically significant reductions in postoperative opioid consumption after arthroscopic surgery. Despite statistically significant findings, observed reductions in postoperative opioid consumption and VAS pain scores may not represent clinically meaningful improvements. The current available literature is highly heterogeneous, indicating the need for high-quality prospective studies to more accurately assess optimal approaches to pain management.