Effects of the Ohio Opioid Prescribing Guidelines on Total Joint Arthroplasty Postsurgical Prescribing and Refilling Behavior of Surgeons and Patients

Opioid Utilization After Primary Total Hip and Knee Arthroplasty Following Sequential Implementation of Statewide Legislation

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.

Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study

INTRODUCTION

Optimized health system approaches to improving guideline-congruent care require evaluation of multilevel factors associated with prescribing practices and outcomes after total knee and hip arthroplasty.

MATERIALS AND METHODS

Electronic health data from patients who underwent a total knee or hip arthroplasty between January 2016-January 2020 in the Military Health System Data were retrospectively analyzed. A generalized linear mixed-effects model (GLMM) examined the relationship between fixed covariates, random effects, and the primary outcome (30-day opioid prescription refill).

RESULTS

In the sample (N = 9151, 65% knee, 35% hip), the median discharge morphine equivalent dose was 660 mg [450, 892] and varied across hospitals and several factors (e.g., joint, race and ethnicity, mental and chronic pain conditions, etc.). Probability of an opioid refill was higher in patients who underwent total knee arthroplasty, were white, had a chronic pain or mental health condition, had a lower age, and received a presurgical opioid prescription (all p < 0.01). Sex assigned in the medical record, hospital duration, discharge non-opioid prescription receipt, discharge morphine equivalent dose, and receipt of an opioid-only discharge prescription were not significantly associated with opioid refill.

CONCLUSION

In the present study, several patient-, care-, and hospital-level factors were associated with an increased probability of an opioid prescription refill within 30 days after arthroplasty. Future work is needed to identify optimal approaches to reduce unwarranted and inequitable healthcare variation within a patient-centered framework.

Opioid Use during Hospitalization following Total Knee Arthroplasty: Trends in Consumption from 2016 to 2021

INTRODUCTION

In response to physician and patient concerns, many institutions have adopted protocols aimed at reducing postoperative opioid consumption after total knee arthroplasty (TKA). Thus, this study sought to examine how consumption of opioids has changed following TKA in the past six years.

METHODS

We conducted a retrospective review of all 10,072 patients who received primary TKA at our institution from January 2016 to April 2021. We collected baseline demographic data including patient age, sex, race, body mass index (BMI), American Society of Anesthesiologist (ASA) classification, as well as dosage and type of opioid medication prescribed on each postoperative day while the patient was hospitalized following TKA. This data was converted to milligram morphine equivalents (MME) per day hospitalized to compare rates of opioid use over time.

RESULTS

Our analysis found the greatest daily opioid use was in 2016 (43.2±68.6 MME/day) and the least was in 2021 (15.0±29.2 MME/day). Linear regression analyses found a significant linear downward trend in postoperative opioid consumption over time, with a decrease of 5.55 MME per day per year (Adjusted R-squared: 0.982, P<0.001). The highest visual analog scale (VAS) score was 4.45 in 2016 and the lowest was 3.79 in 2021 (P<0.001).

CONCLUSION

Opioid reducing protocols have been implemented for patients recovering from primary TKA in an effort to decrease reliance on opioids for postoperative pain control. The results of this study demonstrate that such protocols have been successful in reducing overall opioid use during hospitalization following TKA.

Effects of a Prescription Drug Monitoring Program on Opioid Prescriptions Following Total Joint Arthroplasty in the State of California

In an attempt to reduce opioid prescriptions, the state of California mandated physician participation in the Controlled Substance Utilization Review and Evaluation System (CURES). The goal of this study is to assess whether this intervention led to a change in prescribing habits after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The 90-day postoperative narcotic use was retrospectively reviewed for 13,382 patients undergoing primary THA and TKA. Patients were divided into pre-CURES and post-CURES cohorts based on date of surgery. Narcotic use was measured in morphine milligram equivalents (MME). There was a 21.3% decrease in postoperative MME post-CURES for patients undergoing THA (756.5±759.5 MME vs 962.00±864.4 MME, P<.0001) and a 19.9% decrease in postoperative MME post-CURES for patients undergoing TKA (1274.3±2707.1 MME vs 1590.6±1725.3 MME, P<.0001). Patients post-CURES required an additional prescription at 2 weeks more frequently compared with patients pre-CURES after THA (27.5% vs 20.5%, P<.001) and TKA (54.2% vs 44.2%, P<.001). Patients undergoing THA had 40.5% and 40.6% less narcotic prescribed compared with patients undergoing TKA pre-CURES and post-CURES (P<.001), respectively. Government guidelines led to a substantial decrease in postoperative MME prescribed after TKA and THA. Patients undergoing THA had a substantially smaller amount of narcotic prescribed than patients undergoing TKA. [Orthopedics. 2023;46(2):70-75.].

Opioid Legislation Decreases Opioid Prescribing in Total Knee Arthroplasty

The purpose of this study was to evaluate the impact of opioid-limiting legislation on perioperative opioid prescriptions in total knee arthroplasty. The hypothesis was that opioid legislation has reduced opioid prescription filling above levels anticipated by national trends. This study retrospectively evaluated opioid prescription filling for all patients undergoing total knee arthroplasty in a commercially available insurance database between 2010 and 2018 (n=1,068,764). Initial discharge and 90-day cumulative oxycodone 5-mg equivalents filled were tabulated. Opioid prescription filling was evaluated over time and between states with and without opioid-limiting legislation using analysis of variance and multivariable linear and logistic regression. States with and without opioid legislation had significant reductions in initial and cumulative opioid prescription filling volume (all P<.001). However, the magnitude of this reduction was larger in states with opioid legislation. Legislation targeting duration and volume had the largest impact on initial post-act opioid prescription filling volume compared with states without legislation in an estimated "pre-act" time frame. Legislation targeting duration and volume and no specific target had the largest impact on cumulative post-act opioid prescription filling volume. States without legislation still had large, significant reductions in filling volume, but the magnitude was not as great as in states with opioid legislation. States with and without opioid legislation had significant decreases in initial and cumulative opioid prescription filling volume. However, the magnitude of reduction was larger in states that enacted legislation. Younger age, pre-operative opioid use, and higher comorbidity burden were associated with greater opioid use postoperatively. [Orthopedics. 202x;4x(x):xx-xx.].

Use of a Non-Pharmacological Pain Relief Kit to Reduce Opioid Use Following Orthopedic Surgery: A Prospective Randomized Study

Introduction

Opioid prescription to treat pain among orthopedic surgery patients remains common practice in the United States but overprescribing opioids can lead to abuse. The purpose of this study was to determine the effect of a multimodal non-pharmacological 'pain relief kit' on pain, function, and opioid consumption in individuals recovering from orthopedic surgery.

Hypothesis

Patients provided with the pain relief kit would consume less opioid medication, report lower pain levels, and have better functional outcome scores than the control group.

Level of Evidence

2b.

Methods

Fifty-three subjects (18 women, 35 men) having orthopedic surgery were randomly assigned to either receive the Pain Relief Kit (treatment) or control group. At the first postoperative physical therapy visit (within 1 week of surgery) the treatment group was provided elastic resistance bands, kinesiology tape, Biofreeze, and a hot/cold pack as part of the Pain Relief Kit. Patients completed the SF-36 and either the DASH or LEFS questionnaires consistent with their surgery at baseline and four weeks post-op. Both groups reported daily pain (Visual Analogue Scale), opioid use, and over the counter medication use. The treatment group also recorded daily kit modality use.

Results

There was no significant difference in total opioid use between the treatment (108±252 milligram morphine equivalents) and control groups (132±158 MME; p=0.696). Opioid use and pain declined from week one to four with no difference between groups (p<0.001). Outcome scores and SF-36 scores improved from week one to four with no difference between groups (p<0.001).

Conclusion

A non-pharmacological pain relief kit did not have an effect on opioid use in this patient population nor did it improve pain relief or function compared to controls.

Primary Hemiarthroplasty for the Treatment of Basicervical Femoral Neck Fractures

Purpose

Basicervical femoral neck fractures are uncommon injuries that occur at the extracapsular base of the femoral neck at its transition with the intertrochanteric line. Controversy remains in the orthopedic literature as to the optimal method of treatment for this fracture type given the inherent instability and greater rate of implant failure with traditional fixation constructs. The purpose of this study is to quantify the incidence and preferred treatment methods of basicervical hip fractures at a single, regional, Level 1 trauma center and to identify differences in postoperative complications between treatment options.

Methods

The present study is a retrospective case series from a single regional health network, including 316 patients with hip fractures. Basicervical femoral neck fractures were identified. Reoperation rates within 90 days, implant failures or nonunions, postoperative ambulation distances and range of motion, and discharge dispositions were compared across patients grouped by surgical treatment with either cephalomedullary nail, sliding hip screw, or hemiarthroplasty (HA).

Results

Basicervical femoral neck fractures represented 6.6% of this study population. The cephalomedullary nail group demonstrated rates of implant failure and return to the operating room within 90 days of 40% (4/10) and 20% (2/10), respectively. No patients who underwent hemiarthroplasty experienced a failure of fixation or return to the operating room.

Conclusions

This study suggests a much lower rate of fixation failure or need for reoperation with hemiarthroplasty treatment compared to cephalomedullary nail construct for basicervical femoral neck fractures and may be an underutilized treatment method for this fracture type. The promising results seen with this case series should encourage further investigation into HA as a primary treatment for these uncommon, yet challenging, fractures.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Background

Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.

Methods

This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.

Results

A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.

Conclusions

This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Opioid Claims Prior to Elective Total Joint Arthroplasty and Risk of Prolonged Postoperative Opioid Claims

INTRODUCTION

The United States is experiencing a national opioid epidemic. This study seeks to analyze recent trends in opioid claims after elective total joint arthroplasty and quantify the effect of preoperative opioid use on risk of prolonged postoperative claim rates.

METHODS

A retrospective cohort study was conducted using the PearlDiver database to track annual trends in opioid claims after elective total hip arthroplasty (THA), total knee arthroplasty (TKA), and total shoulder arthroplasty (TSA). Trend analysis of opioid claim rates was done with the Cochran-Armitage test. Rates of postoperative opioid claims were compared between opioid-naïve patients versus patients with opioid claims in the preoperative year through multivariable logistic regression.

RESULTS

In total, 105,860 procedures were included. For all procedures, the proportion of patients filing an opioid claim within 30 days postoperatively trended upward from 2011 to 2017 (all P < 0.001). Patients with one to three opioid claims in the year before arthroplasty were more likely to file an opioid claim within 30 days after arthroplasty (THA: odds ratio [OR], 2.61; TKA: OR, 3.04; and TSA: OR, 4.83), between 31 and 90 days (THA: OR, 2.76; TKA: OR, 2.87; and TSA: OR, 3.22), and between 91 days and 6 months (THA: OR, 4.83; TKA: OR, 4.07; and TSA: OR, 3.77). Patients with more than three prior opioid claims were more likely to file an opioid claim within 30 days (THA: OR, 6.15; TKA: OR, 6.79; and TSA: OR, 8.68), between 31 and 90 days (THA: OR, 20.99; TKA: OR, 14.00; and TSA: OR, 28.40), and between 91 days and 6 months (THA: OR, 46.31; TKA: OR, 33.93; and TSA: OR, 59.06).

CONCLUSION

Opioid claims in the preoperative year markedly increase risk of prolonged postoperative opioid claims after arthroplasty. Surgeons should look further before the acute preoperative period when evaluating opioid exposure and assessing risk of chronic opioid dependence after elective arthroplasty.

LEVEL OF EVIDENCE

Level III.

Long-term opioid use in seniors following hip and knee arthroplasty in Ontario: a historical cohort study

PURPOSE

Canadian seniors who undergo hip and knee arthroplasty often experience significant postoperative pain, which could result in persistent opioid use. We aimed to document the impact of preoperative opioid use and other characteristics on postoperative opioid prescriptions in elderly patients following hip and knee replacement before widespread dissemination of opioid reduction strategies.

METHODS

We conducted a historical cohort study to evaluate postoperative opioid use in patients over 65 yr undergoing primary total hip and knee replacement over a ten-year period from 1 April 2006 to 31 March 2016, using linked de-identified Ontario administrative data. We determined the use of preoperative opioids and the duration of postoperative opioid prescriptions (short-term [1-90 days], prolonged [91-180 days], chronic [181-365 days], or undocumented).

RESULTS

The study included 49,638 hip and 85,558 knee replacement patients. Eighteen percent of hip and 21% of knee replacement patients received an opioid prescription within 90 days before surgery. Postoperatively, 51% of patients filled opioid prescriptions for 1-90 days, while 24% of hip and 29% of knee replacement patients filled prescriptions between 6 and 12 months, with no impact of preoperative opioid use. Residence in long-term care was a significant predictor of chronic opioid use (hip: odds ratio [OR], 2.64; 95% confidence interval [CI], 1.93 to 3.59; knee: OR, 2.46; 95% CI, 1.75 to 3.45); other risk factors included female sex and increased comorbidities.

CONCLUSION

Despite a main goal of joint arthroplasty being relief of pain, seniors commonly remained on postoperative opioids, even if not receiving opioids before surgery. Opioid reduction strategies need to be implemented at the surgical, primary physician, long-term care, and patient levels. These findings form a basis for future investigations following implementation of opioid reduction approaches.

Florida State Opioid Prescription Restriction Law: Impact on Opioid Utilization After Total Joint Arthroplasty

BACKGROUND

In response to the opioid epidemic, Florida recently passed the opioid prescription limiting law, effective since July 1^st, 2018. However, its impact on opioid prescription after total joint arthroplasty (TJA) has not been elucidated. Thus, our objective was to assess if this new law led to reduced opioid prescription after TJA and to determine its impact on perioperative clinical outcomes.

METHODS

A retrospective chart review was conducted on a consecutive series of 658 primary TJAs (618 patients), performed by four surgeons in a single institution [1/2/2018-10/23/2018]. Based on effective date of the law, cases were divided into: prelaw (327 cases; 168 hips/159 knees) and postlaw (331 cases; 191 hips/140 knees) phases. Baseline demographics and surgical characteristics were compared. The effect of the law on perioperative outcomes: length of stay, complications, emergency department/office visits, patient phone calls, reoperation or readmission (90 days), and total morphine equivalents prescribed was investigated. Independent sample t-tests and chi-square analyses were performed.

RESULTS

Prelaw and postlaw phases had no significant difference in baseline demographics and characteristics. No difference was found in length of stay. Opioid law implementation led to significantly lower total oral morphine equivalents after TJAs [Prelaw: 1059.9 ± 825.4 vs postlaw: 942.8 ± 691.7; P = .04], but did not result in a significant increase in 90-day complications, patient visits (office or emergency) or phone calls, and reoperation or readmission.

CONCLUSION

Our data suggest that Florida state opioid prescription limiting law has resulted in a marked decline in opioid prescription without any increase in rates of patient visits, phone calls, or readmission after TJA.

Effect of State Legislation on Discharge Opioid Prescriptions After Total Hip and Knee Arthroplasties

Background

Recent literature suggests that state-level legislation is effective in reducing postoperative opioid prescribing after total joint arthroplasty but has not addressed the effect on opioid antagonist coprescribing. This study aims to describe the change in postoperative opioid and opioid antagonist prescribing patterns after total joint arthroplasty following passage of state-level opioid-limiting legislation and to determine the comorbidities associated with increased opioid prescribing in this population.

Methods

Billing data were used to identify all patients who underwent primary total hip or knee arthroplasty admitted between March 2016 and March 2018 at our institution. The data were divided into 2 cohorts comprising the year before (671 subjects) and after (713 subjects) the legislation. Discharge prescriptions were reviewed, and the median morphine milligram equivalents (MME) per day and naloxone prescriptions were recorded. International Classification of Diseases codes were used to identify comorbid conditions of interest present during previous inpatient or outpatient encounters.

Results

There was a significant reduction in both the minimum and maximum median MME per day after introduction of state legislation and a substantial increase in opioid antagonist coprescription. Total knee arthroplasty, younger age, male sex, chronic pain disorders, post-traumatic stress disorder, and prior opioid abuse were correlated with increased opioid prescribing.

Conclusion

Our findings suggest that state-level legislation is effective in decreasing the MME per day prescribed and increasing opioid antagonist coprescription in the postoperative period for patients undergoing total hip and knee arthroplasties at our institution. These changes may lead to a decrease in opioid-related morbidity and mortality in the patient population undergoing total hip and knee arthroplasties.