How orthopedic surgeons can impact opioid use and dependence in shoulder arthroplasty

Chatha, Kiran; Borroto, Wilfredo J; Goss, Lucas; Ghisa, Claudia; Gilot, Gregory; Sabesan, Vani J.

doi:10.1016/j.jses.2019.10.113

Cited by 12 publications

(11 citation statements)

References 17 publications

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“…Chatha el al reported that TSA patients on preoperative narcotics were 3.5 times more likely to develop postoperative dependence. 7 Similarly, in a cohort of 12,038 TSA patients, Khazi et al identified chronic preoperative opioid use as the strongest risk factor for ongoing use at 12 months postoperatively, followed by chronic lung disease, age <65, chronic pain disorders, psychiatric diagnoses, and EtOH abuse also reaching statistical significance. 13 However, given that these prior studies included patients on preoperative opioids, it is difficult to determine risk factors for those who are opioid naïve preoperatively.…”

Section: Discussionmentioning

confidence: 96%

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Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

et al. 2021

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Introduction Pain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery. Methods The Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months. Results Of the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group ( P < .001). On multivariate analysis, younger age, female gender, and tobacco use, along with the comorbidities of coronary artery disease, clinical depression, diabetes, and rheumatic disease were all found to be predictive factors of prolonged opioid use. Discussion The dose-dependent relationship observed between original opioid prescription data and number of additional refills needed, suggests that initially overprescribing opioids may lead to prolonged dependency. This study also identified several independent risk factors for prolonged opioid use, including younger age, depression, and tobacco use. This study will hopefully help recognize high-risk patient populations and serve as the foundation for future studies into opioid prescription standardization and preoperative opioid education.

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Section: Discussionmentioning

confidence: 96%

“… 21 While the majority of patients achieve sufficient pain control with their original prescription, some go on to require additional refills or progress to prolonged opioid use. 7 , 20 Identifying these patients and associated risk factors is critical as a single postsurgical refill has been shown to increase the potential of misuse by more than 40%. 5 …”

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confidence: 99%

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

et al. 2021

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“…61 While opioids are not a recommended component of the nonoperative management of FAI, up to 45% of patients evaluated for hip arthroscopy for FAI have been prescribed preoperative opioids. 60 This is problematic, as multiple studies have demonstrated that these patients-relative to their opioid-naı ¨ve counterparts-are more likely to be subject to increased postoperative pain, 11 postoperative opioid utilization, [8][9][10]12 complications, 3,26,61,64 and health care utilization 34,61 after various elective orthopaedic procedures. However, the relationship between preoperative opioid use and outcomes after hip arthroscopy for FAI remains unknown.…”

Section: Nonmedical Use Of Prescription Opioids In the Unitedmentioning

confidence: 99%

Association of Preoperative Opioid Use With Complication Rates and Resource Use in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Nazzal

Wilson

Farley

et al. 2021

Orthopaedic Journal of Sports Medicine

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Background: Preoperative opioid use has been shown to be a negative predictor of patient outcomes, complication rates, and resource utilization in a variety of different orthopaedic procedures. To date, there are no studies investigating its effect on outcomes after hip arthroscopy in the setting of femoroacetabular impingement (FAI). Purpose: To determine the association of preoperative opioid use with postoperative outcomes after hip arthroscopy in patients with FAI. Study Design: Cohort study; Level of evidence, 3. Methods: The Truven Health MarketScan Commercial Claims and Encounters Database was queried for all patients who underwent hip arthroscopy for FAI between 2011 and 2018. Opioid prescriptions filled in the 6 months preceding surgery were queried, and the average daily oral morphine equivalents (OMEs) in this period were computed for each patient. Patients were divided into 4 cohorts: opioid naïve, <1 OME per day, 1 to 5 OMEs per day, and >5 OMEs per day. Postoperative 90-day complications, health care utilization, perioperative costs, postoperative opioid use, and 1- and 3-year revision rates were then compared among cohorts. Results: A total of 22,124 patients were ultimately included in this study; 31.2% of these patients were prescribed opioids preoperatively. Overall, the percentage of preoperative opioid-naïve patients increased from 64.5% in 2011 to 78.9% in 2018. Patients who received preoperative opioids had a higher rate of complications, increased resource utilization, and increased revision rates. Specifically, on multivariate analysis, patients taking >5 OMEs per day (compared with patients who were preoperatively opioid naïve) had increased odds of a postoperative emergency department visit (Odds Ratio, 2.23; 95% confidence interval [CI], 1.94-2.56; P < .001), 90-day readmission (OR, 2.25; 95% CI, 1.77-2.87; P < .001), increased acute postoperative opioid use (OR, 25.56; 95% CI, 22.98-28.43; P < .001), prolonged opioid use (OR, 10.45; 95% CI, 8.92-12.25; P < .001), and 3-year revision surgery (OR, 2.14; 95% CI, 1.36-3.36; P < .001). Perioperative adjusted costs were increased for all preoperative opioid users and were highest for the >5 OMEs per day cohort ($6255; 95% CI, $5143-$7368). Conclusion: A large number of patients with FAI are prescribed opioids before undergoing hip arthroscopy, and use of these pain medications is associated with increased health care utilization, increased costs, prolonged opioid use, and early revision surgery.

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“…Limiting access to unused medications while ensuring adequate pain management has been a proposed strategy for improving current prescription practices[ 14 - 16 ]. Although recent studies have highlighted a pattern of patients receiving excess opioid medication after undergoing various orthopedic procedures, there has been minimal evidence to suggest an optimal supply of pain medication postoperatively[ 16 - 23 ]. Therefore, in order to create a safe and effective prescribing guideline that minimizes the over-prescription of opioids and to effectively advise patients pre- and postoperatively, it is imperative to discern the relationship between pain severity and opioid consumption.…”

Section: Introductionmentioning

confidence: 99%

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty

Singh¹,

Tang²,

Bieganowski³

et al. 2022

WJO

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BACKGROUND Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines. AIM To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA. METHODS We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients’ preoperative status using hierarchical Poisson and linear regressions, respectively. RESULTS There were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15. CONCLUSION All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

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How orthopedic surgeons can impact opioid use and dependence in shoulder arthroplasty

Cited by 12 publications

References 17 publications

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

Association of Preoperative Opioid Use With Complication Rates and Resource Use in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty

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