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Kakalecik J, Sipavicius E, Miley EN, Horodyski M, Gray CF, Prieto HA, Parvataneni HK, Deen JT. Opioid Utilization After Primary Total Hip and Knee Arthroplasty Following Sequential Implementation of Statewide Legislation. Arthroplast Today 2024; 25:101275. [PMID: 38229868 PMCID: PMC10790000 DOI: 10.1016/j.artd.2023.101275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/21/2023] [Accepted: 10/19/2023] [Indexed: 01/18/2024] Open
Abstract
Background Following total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased opioid use is associated with poor clinical outcomes. This study investigates implications of Florida legislative mandates on prescribing practices and opioid utilization following primary THA and TKA. Methods We retrospectively reviewed patients undergoing primary TKA or THA between January 1, 2018, to December 31, 2020 at our academic medical center. Three groups were identified: procedures performed prior to mandates, after seven-day prescription limit, and after mandated electronic prescribing. A multivariate analyses of variance evaluated length of stay, morphine milligram equivalents (MMEs), age, body mass index and number of prescription refills. Chi-square tests compared preoperative opioid use, readmissions, and discharge disposition. Results There were 198 patients in group one, 238 patients in group two, and 215 patients in group three (N = 651). Prior to any mandates, patients were prescribed 822.3 + 626.7 MMEs. Following a seven-day prescription limit this decreased to 465.0 + 296.0 MMEs (P < .001), which further decreased after mandated electronic prescribing (228.0 + 284.4 MMEs [P < 0.001]). Patients undergoing THA were prescribed less MME than those undergoing TKA. There was a 2.6% 90-day readmission rate, with no pain-related readmissions. Conclusions Florida legislative mandates for opioid prescription quantities and electronic prescribing have effectively reduced average MMEs prescribed following primary arthroplasty. Despite a shift towards ambulatory surgery, opioid utilization decreased without compromising patient outcomes. These findings underscore the significance of both legislative and surgical practices influencing opioid prescribing habits among orthopaedic surgeons.
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Affiliation(s)
- Jaquelyn Kakalecik
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | | | - Emilie N. Miley
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - MaryBeth Horodyski
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Chancellor F. Gray
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Hernan A. Prieto
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Hari K. Parvataneni
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Justin T. Deen
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
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Lin DY, Samson AJ, D'Mello F, Brown B, Cehic MG, Wilson C, Kroon HM, Jaarsma RL. A multi-disciplinary program for opioid sparse arthroplasty results in reduced long-term opioid consumption: a four year prospective study. BMC Anesthesiol 2023; 23:97. [PMID: 36991313 PMCID: PMC10050824 DOI: 10.1186/s12871-023-02062-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
INTRODUCTION The current opioid epidemic poses patient safety and economic burdens to healthcare systems worldwide. Postoperative prescriptions of opioids contribute, with reported opioid prescription rates following arthroplasty as high as 89%. In this multi-centre prospective study, an opioid sparing protocol was implemented for patients undergoing knee or hip arthroplasty. The primary outcome is to report our patient outcomes in the context of this protocol, and to examine the rate of opioid prescription on discharge from our hospitals following joint arthroplasty surgery. This is possibly associated with the efficacy of the newly implemented Arthroplasty Patient Care Protocol. METHODS Over three years, patients underwent perioperative education with the expectation to be opioid-free after surgery. Intraoperative regional analgesia, early postoperative mobilisation and multimodal analgesia were mandatory. Long-term opioid medication use was monitored and PROMs (Oxford Knee/Hip Score (OKS/OHS), EQ-5D-5 L) were evaluated pre-operatively, and at 6 weeks, 6 months and 1 year postoperatively. Primary and secondary outcomes were opiate use and PROMs at different time points. RESULTS A total of 1,444 patients participated. Two (0.2%) knee patients used opioids to one year. Zero hip patients used opioids postoperatively at any time point after six weeks (p < 0.0001). The OKS and EQ-5D-5 L both improved for knee patients from 16 (12-22) pre-operatively to 35 (27-43) at 1 year postoperatively, and 70 (60-80) preoperatively to 80 (70-90) at 1 year postoperatively (p < 0.0001). The OHS and EQ-5D-5 L both improved for hip patients from 12 (8-19) preoperatively to 44 (36-47) at 1 year postoperatively, and 65 (50-75) preoperatively to 85 (75-90) at 1 year postoperatively (p < 0.0001). Satisfaction improved between all pre- and postoperative time points for both knee and hip patients (p < 0.0001). CONCLUSIONS Knee and hip arthroplasty patients receiving a peri-operative education program can effectively and satisfactorily be managed without long-term opioids when coupled with multimodal perioperative management, making this a valuable approach to reduce chronic opioid use.
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Affiliation(s)
- D-Yin Lin
- Department of Anaesthesia, Flinders Medical Centre, Flinders Drive Bedford Park, Adelaide, SA, 5042, Australia.
- Discipline of Perioperative Medicine, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
| | - Anthony J Samson
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Freeda D'Mello
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Brigid Brown
- Department of Anaesthesia, Flinders Medical Centre, Flinders Drive Bedford Park, Adelaide, SA, 5042, Australia
| | - Matthew G Cehic
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Christopher Wilson
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Surgery, Adelaide Medical School Faculty of Health and Medical Science, University of Adelaide, Adelaide, South Australia, Australia
| | - Ruurd L Jaarsma
- Discipline of Perioperative Medicine, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
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Lan YT, Pagani NR, Chen YW, Niu R, Chang DC, Talmo CT, Hollenbeck BL, Mattingly DA, Smith EL. A Safe Number of Perioperative Opioids to Reduce the Risk of New Persistent Usage Among Opioid-Naïve Patients Following Total Joint Arthroplasty. J Arthroplasty 2023; 38:18-23.e1. [PMID: 35987496 DOI: 10.1016/j.arth.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/07/2022] [Accepted: 08/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Higher initial opioid dosing increases the risk of prolonged opioid use following total joint arthroplasty (TJA), and the safe amounts to prescribe are unknown. We examined the relationship between perioperative opioid exposure and new persistent usage among opioid-naïve patients after total knee and hip arthroplasty. METHODS In this retrospective cohort study, 22,310 opioid-naïve patients undergoing primary TJA between 2018 and 2019 were identified within a commercial claims database. Perioperative opioid exposure was defined as total dose of opioid prescription in morphine milligram equivalents (MME) between 1 month prior to and 2 weeks after TJA. New persistent usage was defined as at least one opioid prescription between 90 and 180 days postoperatively. Multivariate regression analyses were performed to examine the relationship between the perioperative dosage group and the development of new persistent usage. RESULTS For the total patient cohort, 8.1% developed new persistent usage. Compared to patients who received <300 MME, patients who received 600-900 MME perioperatively had a 77% increased risk of developing new persistent usage (odds ratio 1.77, 95% CI, 1.44-2.17), and patients who received ≥1,200 MME perioperatively had a 285% increased risk (odds ratio 3.85, 95% CI, 3.13-4.74). CONCLUSION We found a dose-dependent association between perioperative MME and the risk of developing new persistent usage among opioid-naïve patients following TJA. We recommend prescribing <600 MME (equivalent to 80 pills of 5 mg oxycodone) during the perioperative period to reduce the risk of new persistent usage. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yu-Tung Lan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas R Pagani
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruijia Niu
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carl T Talmo
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Brian L Hollenbeck
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - David A Mattingly
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Eric L Smith
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
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Alexander McIntyre J, Pagani N, Van Schuyver P, Puzzitiello R, Moverman M, Menendez M, Kavolus J. Public Perceptions of Opioid Use Following Orthopedic Surgery: A Survey. HSS J 2022; 18:328-337. [PMID: 35846268 PMCID: PMC9247590 DOI: 10.1177/15563316221097698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023]
Abstract
Background: The United States accounts for the majority of prescription opioids consumed worldwide. Recent literature has focused on opioid prescribing patterns among orthopedic surgeons; however, public and patient expectations about postoperative opioid use remain understudied. Purpose: We sought to explore public perceptions of opioid use after elective orthopedic surgery. Methods: We posted a 32-question survey on Amazon Mechanical Turk (MTurk), an online platform with over 500,000 unique registered users that is a validated tool for collecting survey responses in medical research. The survey asked about attitudes regarding opioid use after elective orthopedic surgery and sociodemographic factors, as well as validated assessments of health literacy and patient engagement. Results: Of 727 respondents who completed surveys, nearly half (46%) said they would prefer nonopioid pain medication after elective orthopedic surgery, although 86% said they would expect to be prescribed opioids for 1 week to 1 month postoperatively. About half said they would expect to be prescribed extra opioid medication in case of unexpected pain following surgery, and 50% reported that they would save their pills to treat future pain. Approximately 63% said they would understand their surgeon's opioid weaning, but over ⅓ said weaning would lead to decreased satisfaction with their surgeon. Roughly ⅔ reported that pain control after surgery would directly affect their opinion of the surgeon. Conclusions: Our survey found that some members of the general public reported expectations regarding postoperative opioid prescribing that could lead to decreased patient satisfaction. These findings suggest the need for further research on the value of preoperative patient education in pain management, on patient expectations of pain control after elective surgery, and on the use of opioids following orthopedic surgery.
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Affiliation(s)
- James Alexander McIntyre
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA,James Alexander McIntyre, MD, Department of
Orthopedic Surgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111,
USA.
| | - Nicholas Pagani
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA
| | | | | | - Michael Moverman
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA
| | - Mariano Menendez
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA
| | - Joseph Kavolus
- Department of Orthopedic Surgery, Tufts
Medical Center, Boston, MA, USA
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Kiani S, Poeran J, Zhong H, Wilson LA, Poultsides L, Liu J, Memtsoudis SG. Tramadol prescribed at discharge is associated with lower odds of chronic opioid use after elective total joint arthroplasty. Reg Anesth Pain Med 2022; 47:rapm-2022-103486. [PMID: 35760515 DOI: 10.1136/rapm-2022-103486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/12/2022] [Indexed: 12/16/2022]
Abstract
INTRODUCTION We aimed to study the association between tramadol prescribed at discharge (after elective total hip and knee arthroplasty (THA/TKA) surgery) and chronic opioid use postoperatively. METHODS This retrospective cohort study queried the Truven MarketScan database and identified patients who underwent an elective THA/TKA surgery between 2016 and 2018 and were prescribed opioids at discharge (n=81 049). Multivariable analysis was conducted to study the association between tramadol prescription at discharge and chronic opioid use, with additional analysis adjusting for the amount of opioids prescribed in oral morphine equivalents. Chronic opioid use was defined as filling ≥10 opioid prescriptions or prescriptions for ≥120 pills within the period from 90 days to 1 year after surgery. RESULTS Overall, tramadol was prescribed at discharge in 11.0% of all THA/TKA cases. Of those, 26.9% and 73.1% received tramadol only or tramadol with another opioid, respectively. Chronic opioid use was observed in 5.4% of cases. After adjustment for relevant covariates, prescription of tramadol combined with another opioid at discharge was associated with lower odds of chronic opioid use comparing to prescription of other opioids (OR 0.69 CI 0.61 to 0.78). DISCUSSION Among patients undergoing elective THA/TKA surgery and discharged with a prescription of opioids, we found that prescription of tramadol combined with another opioid was associated with lower odds of chronic opioid use. This finding must be considered in the context of the tramadol's pharmacology, as well-described genetic differences in metabolism that can make it ineffective in many patients, while for patients with ultrarapid metabolism can cause drug-drug interactions and adverse events, including feelings of high and seizures.
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Affiliation(s)
- Sara Kiani
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jashvant Poeran
- Departments of Orthopedics / Population Health Science & Policy / Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Lazaros Poultsides
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
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