Patient Factors Associated With Prolonged Postoperative Opioid Use After Total Knee Arthroplasty

Namba, Robert S.; Singh, Anshuman; Paxton, Elizabeth W.; Inacio, Maria C.S.

doi:10.1016/j.arth.2018.03.068

Cited by 143 publications

(151 citation statements)

References 22 publications

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“…Our main finding is that obesity was associated with a higher risk ratio for the consumption of all the studied analgesic drugs both pre-and postoperatively. Previously, a higher BMI has been shown to predict NSAID use after THA and TKA [18][19][20] and opioid use after TKA [14,19]. Our study shows that obesity predicts the use of all analgesic drugs (acetaminophen, NSAIDs, and opioids) after hip or knee replacement.…”

Section: Discussionsupporting

confidence: 52%

“…Earlier, controversial results have been reported. Namba et al [14] reported an association with diabetes and increased use of opioids after knee replacement (OR 1.03 [95% CI 1.01-1.05]), whereas in two other studies [9,15], no differences were found after knee or hip replacement regarding diabetes. These differences may be explained by over twofold higher prevalence of diabetes in the study by Namba et al than in the other two and the present study.…”

Section: Discussionmentioning

confidence: 97%

“…Persistent pain may also lead to the increased consumption of analgesics [8]. To date, however, only a limited number of large-scale studies have been conducted on the trajectories of analgesic consumption and the risk factors associated with increased analgesic consumption after surgery [9][10][11][12][13][14][15][16][17][18][19][20][21], even though the risks for adverse events of opioids and non-steroidal anti-inflammatory drugs increase in long-term use [22][23][24], especially in elderly patients with comorbidities. Motivated by the ongoing opioid prescription crisis [25], most recent studies have focused on opioid use after joint replacement and reported higher odds for prolonged postoperative opioid use in association with psychiatric disorders, preoperative opioid use, worse preoperative pain, younger age, cardiac disease, and undergoing knee (compared to hip) surgery [9][10][11][12][13][14][15][16][17]26].…”

Section: Introductionmentioning

confidence: 99%

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Predictors of the use of analgesic drugs 1 year after joint replacement: a single-center analysis of 13,000 hip and knee replacements

et al. 2020

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Background: Pain persists in a moderate number of patients following hip or knee replacement surgery. Persistent pain may subsequently lead to the prolonged consumption of analgesics after surgery and expose patients to the adverse drug events of opioids and NSAIDs, especially in older patients and patients with comorbidities. This study aimed to identify risk factors for the increased use of opioids and other analgesics 1 year after surgery and focused on comorbidities and surgery-related factors. Methods: All patients who underwent a primary hip or knee replacement for osteoarthritis from 2002 to 2013 were identified. Redeemed prescriptions for acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids (mild and strong) were collected from a nationwide Drug Prescription Register. The user rates of analgesics and the adjusted risks ratios for analgesic use 1 year after joint replacement were calculated.Results: Of the 6238 hip replacement and 7501 knee replacement recipients, 3591 (26.1%) were still using analgesics 1 year after surgery. Significant predictors of overall analgesic use (acetaminophen, NSAID, or opioid) were (risk ratio (95% CI)) age 65-74.9 years (reference < 65), 1.1 (1.03-1.2); age > 75 years, 1.2 (1.1-1.3); female gender, 1.2 (1.1-1.3); BMI 30-34.9 kg/m 2 (reference < 25 kg/m 2 ), 1.1 (1.04-1.2); BMI > 35 kg/m 2 , 1.4 (1.3-1.6); and a higher number of comorbidities (according to the modified Charlson Comorbidity Index score), 1. 2 (1.1-1.4). Diabetes and other comorbidities were not significant independent predictors. Of the other clinical factors, the preoperative use of analgesics, 2.6 (2.5-2.8), and knee surgery, 1.2 (1.1-1.3), predicted the use of analgesics, whereas simultaneous bilateral knee replacement (compared to unilateral procedure) was a protective factor, 0.86 (0.77-0.96). Opioid use was associated with obesity, higher CCI score, epilepsy, knee vs hip surgery, unilateral vs bilateral knee operation, total vs unicompartmental knee replacement, and the preoperative use of analgesics/opioids. Conclusions: Obesity (especially BMI > 35 kg/m 2 ) and the preoperative use of analgesics were the strongest predictors of an increased postoperative use of analgesics. It is remarkable that also older age and higher number of comorbidities predicted analgesic use despite these patients being the most vulnerable to adverse drug events.

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Section: Discussionsupporting

confidence: 52%

Section: Discussionmentioning

confidence: 97%

Section: Introductionmentioning

confidence: 99%

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Predictors of the use of analgesic drugs 1 year after joint replacement: a single-center analysis of 13,000 hip and knee replacements

et al. 2020

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“…Our experimental data are consistent with clinical evidence that anxiety in people 435 with joint pain is associated with the greater use of prescription opioids (Barnett et 436 al., 2018), and prolonged use of opioids following total joint replacement for 437 persistent joint pain (Namba et al, 2018). Catastrophizing has also been associated 438 with increased prescription opioid use 4 years following total joint replacement 439 (Valdes et al, 2015).…”

Section: Evidence For Altered Endogenous Opioid Signalling In Wky Ratmentioning

confidence: 99%

Anxiety enhances pain in a model of osteoarthritis and is associated with altered endogenous opioid function and reduced opioid analgesia

Lillywhite

Woodhams

Watson

et al. 2020

Preprint

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Title (20 words): Anxiety enhances pain in a model of osteoarthritis and is 1 associated with altered endogenous opioid function and reduced opioid 2 analgesia 3 4 Abstract 238 words, introduction 629 words, discussion 1138 words 26 27 28 29 30 31 32 Abstract (239) 34Chronic pain states such as osteoarthritis (OA) are often associated with negative 35 affect, including anxiety and depression. This is, in turn, associated with greater 36 opioid analgesic use, potentially contributing to current and future opioid crises. We 37 utilise an animal model to investigate the neurobiological mechanisms underlying 38 increased opioid use associated with high anxiety and chronic pain. 39 Combining a genetic model of negative affect, the Wistar Kyoto (WKY) rat, and intra-40 articular injection of monosodium iodoacetate (MIA; 1mg), our model of high anxiety 41 and augmented OA-like pain behaviour mirrors the clinical problem. Effects of 42 morphine (0.5-6mg.kg -1 ) on pain behaviour and spinal nociceptive neuronal activity 43 were determined in WKY rats, and normo-anxiety Wistar rats, 3 weeks after MIA 44 injection. WKY rats developed augmented OA-like pain, and had blunted inhibitory 45 responses to morphine, when compared to Wistar rats. Potential alterations in 46 endogenous opioid function were probed via systemic blockade of opioid receptors 47 Significance Statement (116) 56 Chronic pain affects large numbers of people, and pain management often relies on 57 poorly effective opioid analgesics, the iatrogenic effects of which are increasingly 58 recognised. The endogenous opioid system -the target for exogenous opioid 59 analgesics -plays key roles in emotional affective states and pain control, but the 60 complex interplay between anxiety, chronic pain, and endogenous opioid system 61 function is challenging to study in people. Here, we have addressed this using a 62 clinically-relevant experimental model. Anxiety-like behaviour was associated with 63 increased chronic arthritis-like pain behaviour, altered opioid receptor function, and 64 reduced efficacy of opioid analgesics. We provide new evidence, which may explain 65 why chronic pain patients with comorbid high anxiety have higher opioid analgesic 66 use. 67Studies were in accordance with UK Home Office Animals (Scientific Procedures) 126 Act (1986) and ARRIVE guidelines (Kilkenny et al., 2012). A total of 183 male rats 127 were used for this study; Wistar n = 97 (Charles River, Margate, United Kingdom), & 128Wistar Kyoto n = 86 (WKY; Envigo, Bicester, United Kingdom). Males only were 129 used to reduce variability in the data, and to maintain consistency with previous 130 studies characterising this model. Wistar rats were used as the most genetically 131 similar control strain to WKY. Rats were group housed by strain in groups of 4 on a 132 12-hour light/dark cycle in a specific pathogen-free environment with ad libitum 133 access to standard rat chow and water. Treatments were randomly assigned to rats, 134 and experimenters were blinded to all treatment group...

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“…Patients taking opioids chronically prior to surgery represent a completely different scenario and present a perioperative challenge as they are more likely to consume higher doses of opioids and rate their pain intensity higher in the first 48 h after TKA than their opioid-naïve counterparts [5]. Namba et al [6] retrospectively studied 23,726 patients who underwent TKA in the Kaiser Permanente system; 60% of the patients in this cohort were taking opioids at the time of surgery. However, although they did report co-morbidities that included 11.6% with chronic back pain and 13.6% with nonspecific chronic pain, the diagnoses for which patients were taking preoperative opioids were not available.…”

Section: Patient Characteristics Associated With Persistent Opioid Usmentioning

confidence: 99%

Managing Prolonged Pain After Surgery: Examining the Role of Opioids

Schwenk

Pozek

Viscusi

2018

The Journal of Arthroplasty

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A notable minority of patients experience persistent postsurgical pain and some of these patients consequently have prolonged exposure to opioids. Risk factors for prolonged opioid use after surgery include preoperative opioid use, anxiety, substance abuse, and alcohol abuse. The window to intervene and potentially prevent persistent opioid use after surgery is short and may best be accomplished by both surgeon and anesthesiologist working together. Anesthesiologists in particular are well positioned in the perioperative surgical home model to affect multiple aspects of the perioperative experience, including tailoring intraoperative medications and providing consultation for possible discharge analgesic regimens that can help minimize opioid use. Multimodal analgesia protocols reduce opioid consumption and thereby reduce exposure to opioids and theoretically the risk of persistent use. Regional anesthesia and analgesia techniques also reduce opioid consumption. Although many patients will recover without difficulty, the small minority who do not should receive customized care which may involve multiple office visits or consultation of a pain specialist. Enhanced recovery pathways are useful in optimizing outcomes after surgery.

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Patient Factors Associated With Prolonged Postoperative Opioid Use After Total Knee Arthroplasty

Cited by 143 publications

References 22 publications

Predictors of the use of analgesic drugs 1 year after joint replacement: a single-center analysis of 13,000 hip and knee replacements

Predictors of the use of analgesic drugs 1 year after joint replacement: a single-center analysis of 13,000 hip and knee replacements

Anxiety enhances pain in a model of osteoarthritis and is associated with altered endogenous opioid function and reduced opioid analgesia

Managing Prolonged Pain After Surgery: Examining the Role of Opioids

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