Trends and predictors of opioid use after total knee and total hip arthroplasty

Abstract

Few studies have assessed postoperative trends in opioid cessation and predictors of persistent opioid use after total knee arthroplasty (TKA) and total hip arthroplasty (THA). Preoperatively 574 TKA and THA patients completed validated, self-report measures of pain, functioning and mood and were longitudinally assessed for 6-months post-surgery. Among patients who were opioid naïve the day of surgery, 8.2% of TKA and 4.3% of THA patients were using opioids at 6 months. In comparison, 53.3% of TKA and 34.7% of THA patients who reported opioid use the day of surgery continued to use opioids at 6 months. Patients taking >60 mg oral morphine equivalents preoperatively had an 80% likelihood of persistent use postoperatively. Day of surgery predictors for 6-month opioid use by opioid naïve patients included greater overall body pain (p=0.002), greater affected joint pain (knee/hip) (p=0.034), and greater catastrophizing (p=0.010). For both opioid naïve and opioid users on day of surgery, decreases in overall body pain from baseline to 6 months were associated with decreased odds of being on opioids at 6 months (aOR=0.72, p=0.050; aOR=0.62, p=0.001); however, change in affected joint pain (knee/hip) was not predictive of opioid use (aOR=0.99, p=0.939; aOR=1.00, p=0.963). In conclusion, many patients taking opioids prior to surgery continue to use opioids after arthroplasty and some opioid naïve patients remained on opioids; however persistent opioid use was not associated with change in joint pain. Given growing concerns about chronic opioid use, the reasons for persistent opioid use and perioperative prescribing of opioids deserve further study.

Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic

“…Patients taking greater than 60mg oral morphine equivalents preoperatively have an 80% likelihood of chronic use 6 months after total knee or hip arthroplasty. 67 …”

What are the advantages of non-opioid analgesic techniques in the management of acute and chronic pain?

“…acute tolerance) [6,7]. In a recently published study [8], investigators reported that for many patients taking opioids before joint replacement surgery, as well as some opioid-naïve patients undergoing arthroplasty procedures, opioid use persisted after surgery despite the absence of joint pain. Retrospective studies have also found an association between the use of large doses of opioid analgesic medication during the perioperative period in patients undergoing primary tumor resections and the recurrence of cancer within 5 years [9].…”

Economic Considerations of Acute Pain Medicine Programs

“…2,44–46 Indeed, work by Goesling and others has demonstrated a much longer duration and consistency of use of opioids following common orthopaedic surgeries than commonly anticipated, often associated with transformation of use patterns from treatment of postoperative pain to treatment of extra-surgical maladies; other related work has demonstrated substantial negative impact of preoperative opioids on postoperative recovery across a range of surgical models. 2,47–50 Economically, this phenomenon further highlights how seemingly cost-effective short-term solutions can lead to drastically increased long-term costs. These costs are often transferred to others within the community and extend beyond healthcare costs to other societal concerns such as law enforcement, employment, and even defense; the cost-effectiveness discussion is thus not constrained to the individual patient, but bridges the conceptual boundaries between personal and population health.…”