Understanding Opioid Use After Total Hip Arthroplasty: A Comprehensive Analysis of a Mandatory Prescription Drug Monitoring Program
JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Authors: Tan, Timothy L.; Rondon, Alexander J.; Wilt, Zachary; Wang, William L.; Kalbian, Irene; Foltz, Carol; Beredjiklian, Pedro K.; Arnold, William V.
Introduction: Opioids remain the most prescribed medication after total hip arthroplasty (THA) despite the potential for abuse and adverse effects. Given the high rates of opioid abuse and potential adverse effects, the reporting of controlled substances is now mandatory in many statewide databases. This study aimed to use a mandatory statewide database to analyze opioid prescription patterns in postoperative THA patients and identify independent risk factors for those patients who need a second prescription and/or require prolonged use (>6 months). Methods: We retrospectively reviewed a consecutive series of 619 primary THAs. Demographic and comorbidity information were collected for all patients. Narcotic prescription data (converted to morphine milligram equivalents) as well as prescription data for sedatives, benzodiazepines, and stimulants were collected from the State's Controlled Substance Monitoring websites 6 months before and 9 months after the index procedure. Bivariate and multivariate analyses were done for second prescription and continued use. Results: Of the 619 patients who underwent THA, 34.9% (216/619) used preoperative opioids, 36.2% (224/619) filled a second opioid prescription, and 10.5% (65/619) had continued use past 6 months. Patients with preoperative opioids were at an approximately 4-fold increased odds of requiring a second script and 12 times odds of continued opioid use. In the multivariate analysis, independent risk factors for requiring a second prescription, in descending order of magnitude, included the use of any sedative or sleep aid prescription and preoperative narcotic use. Independent risk factors for continued narcotic use longer than 6 months after THA included preoperative narcotic use and increased length of stay. Discussion: Several risk factors and their relative weight have been identified for continued narcotic consumption after THA. It is important for surgeons to consider these predisposing factors preoperatively during the informed consent process and for managing postoperative pain expectations.
Perioperative Opioid Use Predicts Postoperative Opioid Use and Inferior Outcomes After Shoulder Arthroscopy
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
Authors: Lu, Yining; Beletsky, Alexander; Cohn, Matthew R.; Patel, Bhavik H.; Cancienne, Jourdan; Nemsick, Michael; Skallerud, William K.; Yanke, Adam B.; Verma, Nikhil N.; Cole, Brian J.; Forsythe, Brian
Purpose: The purpose of this study is to define the impact of preoperative opioid use on postoperative opioid use, patientreported outcomes, and revision rates in a cohort of patients receiving arthroscopic shoulder surgery. Methods: Patients who underwent shoulder arthroscopy were identified from an institutional database. Inclusion criteria were completion of preoperative and postoperative patient-reported outcome measures (PROMs) at 1-year follow-up and completion of a questionnaire on use of opioids and number of pills per day. Outcomes assessed included postoperative PROM scores, postoperative opioid use, persistent pain, and achievement of the patient acceptable symptomatic state. A matched cohort analysis was performed to evaluate the impact of opioid use on achievement of postoperative outcomes, whereas a multivariate regression was performed to determine additional risk factors. Receiver operating characteristic curves were used to establish threshold values in oral morphine equivalents (OMEs) that predicted each outcome. Results: A total of 184 (16.3%) patients were included in the opioid use (OU) group and 1,058 in the no opioid use (NOU) group. The OU and NOU groups showed statistically significant differences in both preoperative and postoperative scores across all PROMs (P <.001). Multivariate logistic regression identified preoperative opioid use as a significant predictor of reduced achievement of the patient acceptable symptomatic state (odds ratio [OR], 0.69, 95% confidence interval [CI], 0.29-0.83, P = .008), increased likelihood of endorsing persistent pain (OR, 1.73, 95% CI, 1.17-2.56, P = .006), and increased opioid use at 1 year (OR, 21.3, 95% CI, 12.2-37.2, P <.001). Consuming a high dosage during the perioperative period increased risk of revision surgery (OR, 8.59, 95% CI, 2.12-34.78, P <.003). Results were confirmed by matched cohort analysis. Receiver operating characteristic analysis found that total OME >1430 mg/d in the perioperative period (area under the curve, 0.76) and perioperative daily OME > 32.5 predicted postoperative opioid consumption (area under the curve, 0.79). Conclusions: Patients with a history of preoperative opioid use can achieve significant improvements in patient-reported outcomes after arthroscopic shoulder surgery. However, preoperative opioid use negatively impacts patients' level of satisfaction and is a significant predictor of pain and continued opioid usage.