Where Are We Now? Few topics in orthopaedic surgery have received as much attention over the past 5 years as opioid prescriptions—and rightfully so. Less than 10 years ago, it was routine to send patients home with 150 opioid tablets after a primary total joint arthroplasty, if not more, often including long-acting opioids like oxycontin [7]. As the opioid epidemic worsened, it became clear that orthopaedic surgeons, as the third-leading prescribers of opioids [4], needed to take an active role in addressing the crisis. State and national governing bodies initially stepped in with guidelines for opioid prescription maximums in the form of a total number of days or oral morphine equivalents [1]. Although well-intentioned, this blunt instrument for change failed to address procedure- and patient-specific needs. No one would argue that pain from a multilevel spine fusion should be treated similarly to pain following a carpal tunnel release. Surgeons and hospital systems responded by creating guidelines of their own to provide a more nuanced balance between appropriate pain control and risk to patients and communities. Our team at the Mayo Clinic began by instituting new opioid prescription maximums that were 30% to 50% less than historic medians for the most common procedures in our department [13]. This achieved the initial aim, demonstrating a 50% decrease in median prescription size and marked decrease in prescription variability without a concomitant increase in refill rates [12]. Nevertheless, we still did not know whether these new targets were accurate based on how much opioid medication patients were taking. Subsequently, a team I was involved with performed a survey study that delineated how much opioid medication patients took after seven common orthopaedic procedures. Among the many takeaways from this study, we found that 60% of opioids went unused, but that the percentage varied greatly based on procedure and patient characteristics [14]. Our center’s guidelines were further refined, but still fail to consider patient-specific risk factors identified in the work such as diagnoses of anxiety or depression, age, and sex to name a few. While previous work has suggested a relationship between anxiety and depression and higher opioid use after surgery, this connection has rarely been specifically investigated. Rajamäki and colleagues [8] provide important new insight on the topic in this issue of Clinical Orthopaedics and Related Research®. Analyzing approximately 20,000 patients who underwent primary THA and TKA between 2002 to 2011, the authors used multiple national registers in Finland to characterize analgesic use primarily based on diagnoses of anxiety, depression, or the use of medications to treat these conditions. If there is one number to remember from this study, it’s two. After controlling for confounding variables, patients with anxiety or depression were roughly two times as likely as patients without those diagnoses to continue using opioids and nonopioid analgesics 1 year after surgery. This figure is troubling, especially as previous work has shown 3% to 6% of patients who were opioid naïve at the time of total joint arthroplasty continue using opioids at 6 to 12 months postoperatively, with rates of 14% to 53% among preoperative opioid users [2, 3]. Based on these discoveries, surgeons should screen patients for anxiety, depression, and related mental health conditions, while working to also understand whether these conditions are well controlled. Just as we should screen patients for diabetes, counsel them on increased risk for infection, and delay surgery if their hemoglobin A1C levels are too high, we should counsel patients with depression or anxiety on possible challenges with pain control and consider delaying surgery if these conditions are not in good control prior to surgery preoperatively. Where Do We Need To Go? Although we have learned much about opioid management, room for substantial further progress exists. The work by Rajamäki and colleagues [8] further underscores the traditional underappreciation of mental health conditions by orthopaedic surgeons and the profound negative consequences this can have on health in general, and surgical outcomes specifically. One cannot help but wonder who is prescribing opioids so long after surgery? It will be important to determine whether orthopaedic surgeons, primary care, pain management, or mental health professionals are responsible for continued long-term prescribing, especially in patients who were opioid naïve at the time of the procedure. The arc of modern medicine continues to bend toward further specialization and multidisciplinary team care. This model can improve certain outcomes but creates an imperative for improved communication and delineation of roles. Orthopaedic surgeons have seen the benefits of this type of comanagement when it comes to older patients or those who are medically complex, specifically in the trauma population. Establishing comanagement with hospital internal medicine teams has benefited outcomes in nearly every metric [5]. Perhaps creating and evaluating similar pathways for mental health and pain management in at-risk patients could yield improvements in care. While we now understand how anxiety and depression impacts long-term analgesic requirements in primary hip and knee arthroplasty in Finland, we need to understand how these relationships may differ in the revision setting, in other countries with higher opioid use (such as the United States), in patients who are opioid naïve versus those who took opioids prior to surgery, and after procedures other than arthroplasty. Another underappreciated and underutilized area within pain management is the wide spectrum of available techniques that do not involve medication. There is a growing body of research within orthopaedic surgery to suggest that tools such as relaxation exercises [11] and cognitive reframing to a positive mindset [6,10] can lower pain scores and quantity of opioid consumption. As alluded to earlier in this article, early guideline efforts to curb opioid prescriptions were crude but have made incremental progress toward specialty and procedure specificity. The next frontier is patient-specific prescribing. How can we create precise yet parsimonious and user-friendly algorithms to predict high versus low opioid requirements, and who may benefit from adjunctive professional co-management? We must answer these questions to achieve the holistic care patients expect of us. How Do We Get There? Many of the knowledge gaps in this space can be adequately addressed by thoughtfully leveraging existing resources, and in some cases, emerging technologies. National and institutional registries and related large databases are well-equipped to evaluate how anxiety/depression influences opioid use in various patient populations. These same resources also are likely to shed light on who is continuing to prescribe opioids to patients (especially those who were previously opioid naïve) several months after surgery. Answers to these questions can influence practice, policy, and provider education. When it comes to developing more precise algorithms, mobile health (or mHealth) technology holds promise for delivering more comprehensive and patient-specific data, with much less risk for confounding and recall bias [9]. Research groups that have developed infrastructure for mHealth initiatives are particularly well-positioned to study these questions, but establishing this capability de novo is becoming increasingly practical. Once surgeons have a better understanding of which patients are at risk, the information becomes useful to the degree which it influences alternative action. Relaxation of electronic prescribing regulations presents an opportunity for such action. Indeed, patients at higher risk of extended opioid use could be given smaller and more-frequent prescriptions. This would potentiate communication and awareness by the surgical teams and provide a greater ability to intervene with patients who are struggling. We may also find that co-management for patients at risk for extended opioid use is a powerful mechanism for change, similar to success in programs for internal medicine co-management of older patients or those with multiple medical comorbid conditions, or co-managment of patients who have periprosthetic joint infections with an infectious disease team [5]. Interested groups could pilot such programs with multidisciplinary expertise for patients at risk of long-term opioid use, and through their own iterative process, educate the orthopaedic community at large on how to better serve our patients. In addition to working with mental health and pain management experts, orthopaedic surgeons need to also assume greater responsibility and screen for these conditions in our patients, and importantly, understand whether they are well or poorly controlled. It took time to adopt similar screening and management protocols for diabetes, smoking, and weight/nutrition management, and the same will be true for mental health conditions and their impact on perioperative pain management. Orthopaedic surgeons will also do well to become more comfortable with nonmedication pain management modalities and study their efficacy in observational, prospective cohort, or randomized clinical trial studies. Our specialty has made gradual, steady progress in pain management, and Rajamäki and colleagues [8] bring timely attention to the impact of mental health on pain management. Following up on their work with targeted studies will be important to continue this progress and enable patient-specific pain management that accounts for comorbidities such as anxiety and depression.