Prescription Opioid Use Before and After Hip Arthroscopy: A Caution to Prescribers

Preoperative opioid use is associated with worse preoperative patient-reported outcomes in hip arthroscopy patients

OBJECTIVES

The purpose of this study was to define the rate of preoperative opioid use among patients undergoing hip arthroscopy, ascertain which clinical factors are associated with opioid use, and assess the effect of preoperative opioid usage on preoperative patient-reported outcome (PRO) measures.

METHODS

A single institution orthopedic registry was retrospectively analyzed for patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) syndrome with or without labral tear between 2015 and 2022. Patients completed Patient-Reported Outcomes Measurement Information System (PROMIS) in six domains, Numeric Pain Scores (NPS), and Musculoskeletal Outcomes Data Evaluation and Management System expectations domain preoperatively. Patients' charts were reviewed to determine demographic factors and identify any active opioid prescription within 6 weeks before surgery. Bivariate analysis was used to determine associations between preoperative opioid use and baseline PROs. Statistically significant bivariate associations were further tested by multivariate analysis to determine independent predictors.

RESULTS

A total of 123 patients were included (age 39.7 ​± ​12.0 years; 87 females; body mass index 27.4 ​± ​5.7 kg/m2). There were 21 patients (17%) using opioids preoperatively. Prior orthopedic or other surgery and lower education level were associated with preoperative opioid use. Patients with preoperative opioid use scored statistically significantly worse compared with those without preoperative opioid use on baseline PROMIS Physical Function (38.6 vs 40.5, p ​= ​0.01), Pain Interference (65.9 vs 60.2, p ​= ​0.001), Fatigue (60.7 vs 51.6, p ​= ​0.005), Social Satisfaction (38.2 vs 43.2, p ​= ​0.007), and Depression (54.2 vs 48.8, p ​= ​0.01). Preoperative opioid use was also associated with statistically significantly worse preoperative NPS for both the operative hip (6.3 vs 4.6, p ​= ​0.003) and whole body (3.0 vs 1.4, p ​= ​0.008). Preoperative opioid use was an independent predictor of worse baseline PROMIS Pain Interference, Fatigue, Social Satisfaction, and NPS for the operative hip.

CONCLUSION

Patients using opioids preoperatively had worse baseline PROs for physical function, pain, social satisfaction, and depression than those not using opioids preoperatively. When controlling for confounding variables, preoperative opioid use was independently predictive of worse baseline pain, fatigue, and social satisfaction.

LEVEL OF EVIDENCE

Level III, prognostic study.

Prior Diagnosis of Opioid-Related Disorder Is Associated With Higher Medical Resource Utilization Following Primary Hip Arthroscopy: A National Database Study

PURPOSE

To compare adverse events, medical resource utilization, prescribing patterns, and revision surgery rates of patients with opioid-related disorders (ORDs) undergoing primary hip arthroscopy against a propensity-matched group with no opioid-related disorders (NORDs).

METHODS

The TriNetX database was queried between January 2015 and December 2020 using International Classification of Diseases, 10th Revision and Current Procedural Terminology codes to identify patients undergoing primary hip arthroscopy between ages 18 and 70 years. The ORD cohort was propensity matched in a 1:1 ratio to NORD patients based on age, sex, alcohol-related disorders, heart disease, hypertension, metabolic disorders, anxiety disorders, major depressive disorder, diabetes mellitus, and antidepressant prescriptions. Postoperative rates of adverse events and medical resources were compared within 90 days of procedure, prescriptions were compared within 1 year, and revision surgery was compared within 2 years.

RESULTS

A total of 809 ORD patients were propensity matched in a 1:1 ratio to NORD patients. Postoperative adverse events were similar between groups (P = .693). Rates of revision arthroscopy were also similar for both ORD (9.3%) and NORD (8.0%) cohorts (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.83-1.66; P = .377). ORD patients received care from the emergency department, inpatient admission, outpatient visit, and physical therapy evaluations at higher rates. The ORD cohort received a greater amount of new opioid (OR, 2.66; 95% CI, 2.17-3.26; P < .0001) and antidepressant prescriptions (OR, 1.58; 95% CI, 1.26-1.97; P < .0001) compared to NORD patients within 1 year of surgery.

CONCLUSIONS

ORD patients demonstrated similar rates of adverse events and revision surgery when compared to a propensity-matched group of NORD patients undergoing primary hip arthroscopy. However, ORD patients experienced increased rates of emergency department visits and hospitalizations and were prescribed higher rates of opioid and antidepressant prescriptions.

LEVEL OF EVIDENCE

Level III, cohort study.

Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction

Purpose

To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR).

Methods

Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users.

Results

Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively.

Conclusions

This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use.

Level of Evidence

Level III, retrospective cohort study.

A Neural Network Model Using Pain Score Patterns to Predict the Need for Outpatient Opioid Refills Following Ambulatory Surgery: Algorithm Development and Validation

BACKGROUND

Expansion of clinical guidance tools is crucial to identify patients at risk of requiring an opioid refill after outpatient surgery.

OBJECTIVE

The objective of this study was to develop machine learning algorithms incorporating pain and opioid features to predict the need for outpatient opioid refills following ambulatory surgery.

METHODS

Neural networks, regression, random forest, and a support vector machine were used to evaluate the data set. For each model, oversampling and undersampling techniques were implemented to balance the data set. Hyperparameter tuning based on k-fold cross-validation was performed, and feature importance was ranked based on a Shapley Additive Explanations (SHAP) explainer model. To assess performance, we calculated the average area under the receiver operating characteristics curve (AUC), F1-score, sensitivity, and specificity for each model.

RESULTS

There were 1333 patients, of whom 144 (10.8%) refilled their opioid prescription within 2 weeks after outpatient surgery. The average AUC calculated from k-fold cross-validation was 0.71 for the neural network model. When the model was validated on the test set, the AUC was 0.75. The features with the highest impact on model output were performance of a regional nerve block, postanesthesia care unit maximum pain score, postanesthesia care unit median pain score, active smoking history, and total perioperative opioid consumption.

CONCLUSIONS

Applying machine learning algorithms allows providers to better predict outcomes that require specialized health care resources such as transitional pain clinics. This model can aid as a clinical decision support for early identification of at-risk patients who may benefit from transitional pain clinic care perioperatively in ambulatory surgery.

Improved Pain and Perioperative Outcomes After Hip Arthroscopy With the Pericapsular Nerve Group Block

PURPOSE

To compare early postoperative pain in patients undergoing hip arthroscopy with versus without the pericapsular nerve group (PENG) block.

METHODS

A retrospective chart review of prospectively collected data was performed to identify patients who underwent hip arthroscopy at a single institution between May 2019 and October 2021. Patients were included if they received general anesthesia and were opioid naive. Patients who received the PENG block were compared with patients who did not. Opioid, benzodiazepine, and antiemetic medication administration was recorded both intraoperatively and for the duration of the patient's stay in the postanesthesia care unit (PACU). Opioids administered were converted to morphine milligram equivalents (MMEs). Pain was assessed with a visual analog scale. Time to discharge (in minutes) and complications were recorded.

RESULTS

A total of 53 patients were identified for inclusion, of whom 28 received the PENG block and 25 did not. Opioid consumption was significantly lower in the PENG block group both intraoperatively (16.9 ± 14.1 MMEs vs 40.6 ± 18.3 MMEs, P < .001) and in the PACU (14.4 ± 11.4 MMEs vs 31.2 ± 20.1 MMEs, P < .001). The highest recorded PACU pain score was significantly greater in the no-PENG block group (7.0 ± 1.9 vs 5.3 ± 2.1, P = .004). Within the PENG block group, fewer patients required antiemetics (0 vs 4, P = .043). There was a greater time to discharge in the no-PENG block group (161 ± 50 minutes vs 129 ± 34 minutes, P = .008). No complications, including postoperative falls, were noted in either group.

CONCLUSIONS

The PENG block improves perioperative outcomes by decreasing pain, opioid consumption, time to discharge, antiemetic requirements, and benzodiazepine requirements after hip arthroscopy.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Patient-specific factors, but neither regional anesthesia nor hip-specific cryotherapy, predict postoperative opioid requirements after hip arthroscopy for femoroacetabular impingement (FAI) syndrome

Background

We sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy.

Methods

104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length.

Results

The average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed.

Conclusion

Patient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system.

Level of evidence

III, retrospective cohort study.

A Machine-Learning Algorithm to Predict the Likelihood of Prolonged Opioid Use Following Arthroscopic Hip Surgery

PURPOSE

To develop a machine-learning algorithm and clinician-friendly tool predicting the likelihood of prolonged opioid use (>90 days) following hip arthroscopy.

METHODS

The Military Data Repository was queried for all adult patients undergoing arthroscopic hip surgery between 2012 and 2017. Demographic, health history, and prescription records were extracted for all included patients. Opioid use was divided into preoperative use (30-365 days before surgery), perioperative use (30 days before surgery through 14 days after surgery), postoperative use (14-90 days after surgery), and prolonged postoperative use (90-365 days after surgery). Six machine-learning algorithms (Naïve Bayes, Gradient Boosting Machine, Extreme Gradient Boosting, Random Forest, Elastic Net Regularization, and artificial neural network) were developed. Area under the receiver operating curve and Brier scores were calculated for each model. Decision curve analysis was applied to assess clinical utility. Local-Interpretable Model-Agnostic Explanations were used to demonstrate factor weights within the selected model.

RESULTS

A total of 6,760 patients were included, of whom 2,762 (40.9%) filled at least 1 opioid prescription >90 days after surgery. The artificial neural network model showed superior discrimination and calibration with area under the receiver operating curve = 0.71 (95% confidence interval 0.68-0.74) and Brier score = 0.21 (95% confidence interval 0.20-0.22). Postsurgical opioid use, age, and preoperative opioid use had the most influence on model outcome. Lesser factors included the presence of a psychological comorbidity and strong history of a substance use disorder.

CONCLUSIONS

The artificial neural network model shows sufficient validity and discrimination for use in clinical practice. The 5 identified factors (age, preoperative opioid use, postoperative opioid use, presence of a mental health comorbidity, and presence of a preoperative substance use disorder) accurately predict the likelihood of prolonged opioid use following hip arthroscopy.

LEVEL OF EVIDENCE

III, retrospective comparative prognostic trial.

Effect of Perioperative Opioid Use on Patients Undergoing Hip Arthroscopy

Background

Opioids are commonly used to treat postoperative pain; however, guidelines vary regarding safe opioid use after hip arthroscopy.

Purpose/Hypothesis

The purposes were to (1) identify risk factors for persistent opioid use, (2) assess the effect of opioid use on outcomes, and (3) describe common opioid prescribing patterns after hip arthroscopy. It was hypothesized that preoperative opioid use would affect complication rates and result in greater postoperative opioid use.

Study Design

Case-control study; Level of evidence 3.

Methods

The Utah State All Payer Claims Database was queried for patients who underwent hip arthroscopy between January 2013 and December 2017. Included were patients ≥14 years of age at index surgery with continuous insurance. Patients were separated into acute (<3 months) and chronic (≥3 months) postoperative opioid use groups. Primary outcomes included revision surgery, complications (infection, pulmonary embolism/deep venous thrombosis, death), emergency department (ED) visits, and hospital admissions. Multivariate logistic regression was utilized to identify factors associated with the outcomes.

Results

Included were 2835 patients (mean age, 47 years; range, 14-64 years), of whom 2544 were in the acute opioid use and 291 were in the chronic opioid use group. Notably, 91% of the patients in the chronic group took opioid medications preoperatively, and they were more than twice as likely to carry a mental health diagnosis (P < .01). Patients in the acute group had a significantly shorter initial prescription duration, took fewer opioid pills, and had fewer refills than those in the chronic group (P < .01 for all). Patients in the chronic group had a significantly higher risk of postoperative ED visits (odds ratio [OR], 2.76; P = .008), hospital admission (OR, 3.02; P = .002), and additional surgery (P = .003), as well as infection (OR, 2.55; P < .001) and hematoma (OR, 2.43; P = .030). Patients who had used opioids before hip arthroscopy were more likely to need more refills (P < .01). A formal opioid use disorder diagnosis correlated significantly with postoperative hospital admissions (OR, 3.83; P = .044) and revision hip arthroscopy (OR, 4.72; P = .003).

Conclusion

Mental health and substance use disorders were more common in patients with chronic postoperative opioid use, and chronic postoperative opioid use was associated with greater likelihood of postoperative complications. Preoperative opioid use was significantly correlated with chronic postoperative opioid use and with increased refill requests after index arthroscopy.

Prolonged Postoperative Opioid Use After Arthroscopic Femoroacetabular Impingement Syndrome Surgery: Predictors and Outcomes at Minimum 2-Year Follow-up

Background:

The association between prolonged postoperative opioid use on outcomes after hip preservation surgery is not known.

Purpose:

To compare minimum 2-year patient-reported outcomes (PROs) between patients who required ≥1 postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) versus patients who did not require a refill and to identify preoperative predictors for patients requiring ≥1 postoperative opioid refill.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data from consecutive patients who underwent arthroscopic surgery for FAIS between January 2012 and January 2017 were analyzed. Multivariate regression analysis was performed to classify patient and radiographic variables as predictive of requiring ≥1 opioid prescription refill after surgery. Patients completed the following PROs preoperatively and at 2-year follow-up: Hip Outcome Score— Activities of Daily Living subscale (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-12), and 100-point visual analog scale (VAS) for pain and satisfaction. Scores were compared between patients needing additional prescription opioids and those who did not.

Results:

A total of 775 patients, of whom 141 (18.2%) required ≥1 opioid prescription refill, were included in the analysis. Patients requiring opioid refills had significantly lower 2-year postoperative PRO scores compared with patients not requiring refills: HOS-ADL (79.9 ± 20.3 vs 88.7 ± 14.9), HOS-SS (64.6 ± 29.5 vs 78.2 ± 23.7), mHHS (74.2 ± 21.1 vs 83.6 ± 15.9), iHOT-12 (63.6 ± 27.9 vs 74.9 ± 24.8), and VAS satisfaction (73.4 ± 30.3 vs 82.2 ± 24.9), as well as significantly more pain (26.8 ± 23.4 vs 17.9 ± 21.8) (P ≤ .001 for all). Predictors of requiring a postoperative opioid refill included patients with active preoperative opioid use (odds ratio, 3.12 [95% confidence interval, 1.06-9.21]; P = .039) and larger preoperative alpha angles (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .03).

Conclusion:

Patients requiring ≥1 opioid prescription refill after hip arthroscopy for FAIS had lower preoperative and 2-year PRO scores when compared with patients not requiring refills. Additionally, active opioid use at the time of surgery was found to be predictive of requiring additional opioids for pain management.

Fascia Iliaca Block for Postoperative Pain Control After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy.

PURPOSE

To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was "hip arthroscopy fascia iliaca randomized." Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption.

RESULTS

Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, -0.2 [95% CI, -1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities.

CONCLUSION

In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.

Associations between preoperative depression and opioid use after anterior cruciate ligament reconstruction and concomitant procedures

Objectives: To determine rates of perioperative opioid use and characterize associations between preoperative depression and chronic and cumulative opioid consumption after ACL reconstruction.Methods: Using insurance claims data, we identified 48,657 adults who underwent ACL reconstruction from 2010 to 2015, had prescription drug insurance, and had ≥1 year of continuous insurance enrollment postoperatively. Chronic opioid use was defined as filling ≥120 days' supply from 3 to 12 months postoperatively. Logistic and linear regression, controlled for age, sex, and Charlson Comorbidity Index value, were used to determine associations of preoperative depression with binary and continuous outcomes, respectively.Results: Preoperatively, 2,237 patients (4.6%) had depression and 2,387 (4.9%) were taking opioids; patients with depression had 6.5 times the odds (95% confidence interval [CI]: 5.8, 7.3) of taking opioids than patients without depression. Postoperatively, 25% of the patients filled ≥1 opioid prescription; mean duration of use was 13 ± 11 days, and 362 patients (0.7%) had chronic use. Patients with preoperative depression were less likely than patients without depression to fill an opioid prescription postoperatively (OR 0.2, 95% CI: 0.2, 0.2). Of patients who filled opioid prescriptions postoperatively, those with preoperative depression were more likely to refill that prescription at least once (OR 2.0, 95% CI: 1.9, 2.2) but did not have greater odds of chronic use (OR 0.9, 95% CI: 0.5, 1.5). Preoperative depression was not associated with greater cumulative opioid consumption from 3 to 12 months postoperatively (β = -40, 95% CI: -226, 146).Conclusion: Although patients with preoperative depression were more likely to take opioids preoperatively and to obtain ≥1 opioid refill postoperatively, they did not have greater odds of chronic postoperative opioid use or greater cumulative opioid consumption after ACL reconstruction.

The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular Impingement According to the International Hip Outcome Tool-12 and Hip Outcome Score Sports Subscale

BACKGROUND

A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool-12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership.

RESULTS

A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers' compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores.

CONCLUSION

Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers' compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.

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.

Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age

PURPOSE

Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use.

METHODS

A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60 years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1 year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15 months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage.

RESULTS

Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1 year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15 months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use.

CONCLUSION

Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use.

LEVEL OF EVIDENCE

Level III.

Machine Learning Algorithms Predict Prolonged Opioid Use in Opioid-Naïve Primary Hip Arthroscopy Patients

Introduction:

Excessive opioid use after orthopaedic surgery procedures remains a concern because it may result in increased morbidity and imposes a financial burden on the healthcare system. The purpose of this study was to develop machine learning algorithms to predict prolonged opioid use after hip arthroscopy in opioid-naïve patients.

Methods:

A registry of consecutive hip arthroscopy patients treated by a single fellowship-trained surgeon at one large academic and three community hospitals between January 2012 and January 2017 was queried. All patients were opioid-naïve and therefore had no history of opioid use before surgery. The primary outcome was prolonged postoperative opioid use, defined as patients who requested one or more opioid prescription refills postoperatively. Recursive feature elimination was used to identify the combination of variables that optimized model performance from an initial pool of 17 preoperative features. Five machine learning algorithms (stochastic gradient boosting, random forest, support vector machine, neural network, and elastic-net penalized logistic regression) were trained using 10-fold cross-validation five times and applied to an independent testing set of patients. These algorithms were assessed by calibration, discrimination, Brier score, and decision curve analysis.

Results:

A total of 775 patients were included, with 141 (18.2%) requesting and using one or more opioid refills after primary hip arthroscopy. The stochastic gradient boosting model achieved the best performance (c-statistic: 0.75, calibration intercept: −0.02, calibration slope: 0.88, and Brier score: 0.13). The five most important variables in predicting prolonged opioid use were the preoperative modified ones: Harris hip score, age, BMI, preoperative pain level, and worker's compensation status. The final algorithm was incorporated into an open-access web application available here: https://orthoapps.shinyapps.io/HPRG_OpioidUse/.

Conclusions:

Machine learning algorithms demonstrated good performance for predicting prolonged opioid use after hip arthroscopy in opioid-naïve patients. External validation of this algorithm is necessary to confirm the predictive ability and performance before use in clinical settings.

Risk factors for new chronic opioid use after hip fracture surgery: a Danish nationwide cohort study from 2005 to 2016 using the Danish multidisciplinary hip fracture registry

OBJECTIVE

To examine the risk factors for new chronic opioid use in elderly patients who underwent hip fracture surgery.

DESIGN

Prospective population-based cohort study.

SETTING AND PARTICIPANTS

Using Danish nationwide health registries, we identified all opioid non-user patients aged ≥65 years who had undergone hip fracture surgery from 2005 to 2016 and were alive within the first year following surgery.

MAIN OUTCOME MEASURES

New chronic opioid use defined by the dispensing of at least two prescription opioids within two of the last three quarters during the first year following surgery.

RESULTS

We identified 37 202 opioid non-user patients who underwent hip fracture surgery. Of these, 5497 (15%) developed new chronic opioid user within 1 year of surgery. Risk factors for new chronic opioid use were Body Mass Index (BMI) of <18.5 (adjusted OR (aOR) 1.22, 95% CI 1.09 to 1.36), BMI of 25.0-29.9 (aOR 1.12, 95% CI 1.04 to 1.21) and BMI of ≥30 (aOR 1.57, 95% CI 1.40 to 1.76) with BMI 18.6-24.9 as reference, a pertrochanteric/subtrochanteric fracture (aOR 1.27, 95% CI 1.20 to 1.34) with femoral neck fracture as reference, preoperative use (vs no-use) of non-steroidal anti-inflammatory drug (aOR 1.68, 95% CI 1.55 to 1.83), selective serotonin reuptake inhibitor (aOR 1.42, 95% CI 1.32 to 1.53), antidepressants (aOR 1.36, 95% CI 1.24 to 1.49), antipsychotics (aOR 1.21, 95% CI 1.07 to 1.35), corticosteroids (aOR 1.54, 95% CI 1.35 to 1.76), statins (aOR 1.09, 95% CI 1.02 to 1.18), antibiotics (aOR 1.32, 95% CI 1.22 to 1.42), antiosteoporosis drugs (aOR 1.33, 95% CI 1.19 to 1.49) and anticoagulatives (aOR 1.24, 95% CI 1.17 to 1.32). Presence of cardiovascular comorbidities, diabetes, gastrointestinal diseases, dementia, chronic obstructive pulmonary disease or renal diseases was further identified as a risk factor.

CONCLUSION

In this large nationwide cohort study, we identified several risk factors associated with new chronic opioid use after hip fracture surgery among patients who were alive within the first year following surgery. Although not all factors are modifiable preoperative, this will allow clinicians to appropriately counsel patients preoperatively and tailor postoperative treatment.

Increased Prevalence and Associated Costs of Psychiatric Comorbidities in Patients Undergoing Sports Medicine Operative Procedures

PURPOSE

To evaluate the prevalence of preoperatively diagnosed psychiatric comorbidities and the impact of these comorbidities on the healthcare costs of ten common orthopaedic sports medicine procedures.

METHODS

Patients undergoing 10 common sports medicine procedures from 2007 to 2017q1 were identified using the Humana claims database. These procedures included anterior cruciate ligament reconstruction; posterior cruciate ligament reconstruction; medial collateral ligament repair/reconstruction; Achilles repair/reconstruction; Rotator cuff repair; meniscectomy/meniscus repair; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability procedures; and shoulder instability repair. Patients were stratified by preoperative diagnoses of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity (psychiatric) versus those without psychiatric comorbidities (no psychiatric). Differences in costs across groups were compared using Mann-Whitney U tests, with significance defined as P < .05. Linear regression analysis was used to assess rates of procedures per year from 2006 to 2016.

RESULTS

In total, 226,402 patients (57.7% male) from 2007 to 2017q1 were assessed. The prevalence of ≥1 psychiatric comorbidity within the entire database was 10.31% (reference) versus 21.21% in those patients undergoing the 10 investigated procedures. Patients with psychiatric comorbidity most frequently underwent rotator cuff repair (28%), hip labral repair (26.3%) and meniscectomy/meniscus repair (25.0%%) had ≥1 psychiatric comorbidity. Compared with the no psychiatric cohort, diagnosis of ≥1 psychiatric comorbidity was associated with increased health care costs for all 10 sports medicine procedures ($9678.81 vs $6436.20, P < .0001).

CONCLUSIONS

The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures is high. The presence of psychiatric comorbidities preoperatively was associated with increased postoperative costs following all investigated orthopaedic sports medicine procedures.

LEVEL OF EVIDENCE

Level III; retrospective comparative study.

Editorial Commentary: Hip Arthroscopists Can Reduce Postoperative Opioid Use

Despite the harrowing opioid crisis in the United States, the use of opioids to combat musculoskeletal pain continues to be widespread. In the setting of hip arthroscopy, approximately one-third of patients are on opioids while awaiting surgery to address the pain that results from femoracetabular impingement syndrome. In addition, the use of opioids to address pain postoperatively is common practice. With the rapid rise of hip arthroscopy in the United States, it is paramount that other modes of pain relief are promoted by surgeons in conjunction with allied health professionals, such as physical therapists. In fact, early physical therapy has been shown to decrease the use of postoperative opioids by 10%. The use of complementary and alternative therapies should be common practice in the in the orthopaedic setting to assist in reducing the number of opioids used for both pre and postoperative pain management. While this may be a small piece of the opioid crisis puzzle, it is up to all of us in the medical community to do our part and change the direction of the current opioid crisis.

What Is the Survivorship After Hip Arthroscopy for Femoroacetabular Impingement? A Large-database Study

BACKGROUND

Patients with femoroacetabular impingement (FAI) may experience lasting clinical improvement after hip arthroscopy; however, some patients will still eventually undergo early conversion to THA due to unresolved symptoms and progression of arthritis. However, the risk of this has been only incompletely characterized in prior studies.

QUESTIONS/PURPOSES

Using a large healthcare claims database over a 5-year period (2011-2016), we asked: (1) What is the survivorship free from THA after arthroscopic osteoplasty performed for FAI? (2) What identifiable demographic factors and patient characteristics are associated with early conversion to THA after hip arthroscopy performed for FAI?

METHODS

We included all patients who underwent hip arthroscopy for FAI, between the ages of 12 years and 63 years, with 3 months of claims data before hip arthroscopy and minimum 2-year follow-up. A total of 4730 hip arthroscopy patients from 2011 to 2014 were retrieved from a US commercial claims database. Hip arthroscopy incidence doubled over time from 1.2 to 2.1 persons per 100,000. Temporal trends, patient demographics, diagnoses at time of arthroscopy, and patient comorbidities were retrieved and logistic regression performed. Survivorship analysis on 11,323 patients (lifting the 2-year follow-up requirement) was also performed to identify independent variables associated with early risk of conversion to THA.

RESULTS

In patients undergoing hip arthroscopy for FAI, the overall proportion of conversion to THA within 2 years after hip arthroscopy was 7% (338 of 4730). After controlling for confounding variables such as sex, obesity, and depression, we found the following were independently associated with increased odds of conversion to THA: older age (odds ratio 1.08 [95% CI 1.01 to 1.10]; p < 0.001), osteoarthritis (OR 2.91 [95% CI 2.27 to 3.77]; p < 0.001), joint inflammation (OR 1.89 [95% CI 1.16 to 3.09]; p = 0.01), and a history of opioid use (OR 2.17 [95% CI 1.69 to 2.79]; p < 0.001). Survivorship analysis similarly revealed that older age (hazard ratio 1.08 [95% CI 1.07 to 1.09]; p < 0.001), osteoarthritis (HR 2.53 [95% CI 2.13 to 3.01]; p < 0.001), joint inflammation (HR 1.53 [95% CI 1.10 to 2.11]; p = 0.01), a history of opioid use (HR 2.02 [95% CI 1.71 to 2.38]; p < 0.001), and smoking (HR 1.55 [95% CI 1.14 to 2.11]; p = 0.005), were independently associated with increased odds of conversion to THA within 2 years after hip arthroscopy for FAI.

CONCLUSIONS

Although the findings of this study are limited and should not be taken in isolation, patients with FAI who are older, carry diagnoses of inflammatory or degenerative articular disease, or who use opioids or smoke should be counseled about a potentially increased risk of undergoing early conversion to THA after hip arthroscopy. Future studies to further examine the effect of these diagnoses in prospectively collected cohorts, incorporating radiographic and patient-reported outcome measures, are needed.

LEVEL OF EVIDENCE

Level III, prognostic study.

Preoperative Opioid Usage, Male Sex, and Preexisting Knee Osteoarthritis Impacts Opioid Refills After Isolated Arthroscopic Meniscectomy: A Population-Based Study

PURPOSE

To identify risk factors for opioid consumption after arthroscopic meniscectomy using a large national database.

METHODS

Patients undergoing primary arthroscopic meniscectomy from 2007 to 2016 were retrospectively accessed from the Humana database. Patients were categorized as those who filled opioid prescriptions within 3 months (OU), within 1 month (A-OU), between 1 and 3 months (C-OU), and never filled opioid prescriptions (N-OU) before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for each cohort. Prolonged opioid use was defined as continued opioid prescription filling at ≥3 months after surgery. Multiple logistic regression analysis was used to identify factors associated with opioid refills at 12 months after surgery.

RESULTS

There were 88,120 patients (53.7% female) who underwent arthroscopic meniscectomy, of whom 46.1% (n = 39,078) were N-OU. About a quarter (25.3%) of patients continued filling opioid prescriptions at 1 year postoperatively. In addition, opioid fill rate at 1 year was significantly greater in the OU group compared with the N-OU group with a relative risk of 2.89 (40.7% vs 14.1%; 95% confidence interval 2.81-2.98; P < .0001). Multiple logistic regression model identified C-OU (odds ratio 3.67; 95% confidence interval 3.53-3.82; P < .0001) as the strongest predictor of opioid use at 12 months postoperatively. Furthermore, male sex, A-OU, knee osteoarthritis, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, fibromyalgia, anxiety or depression, alcohol use disorder, and tobacco use (P < .02 for all) had significantly increased odds of opioid use at 12 months postoperatively. However, patients <40 years (P < .0001) had significantly decreased odds of opioid use 12 months postoperatively.

CONCLUSIONS

Preoperative opioid filling is a significant risk factor for opioid use at 12 months postoperatively. Male sex, preexisting knee osteoarthritis, and diagnosis of anxiety or depression were independent risk factors for opioid use 12 months following arthroscopic meniscectomy.

LEVEL OF EVIDENCE

Level-III, Retrospective Cohort Study.

Editorial Commentary: How to Reduce Postoperative Shoulder Pain in Your Practice-Stick to Instability and Opioid-Naive Patients

Preoperative opioid use independently predicts persistent postoperative use after most surgical procedures, and surgery on the shoulder (and labrum specifically) is no exception. Thoughtful preoperative counseling of patients regarding the risks of continued postoperative opioid use, dangers of long-term narcotic use, expectations for postoperative pain control, and potential negative effect on postoperative outcomes is time-consuming and not easy. It is important to note that we have yet to determine whether preoperative opioid users can be restored to an opioid-naive state regarding the associated superior patient-reported outcomes observed postoperatively. Indications for surgery are important predictors of outcomes as well-athletes we treat for shoulder instability do not often present with pain unless associated with an acute instability event. Therefore, postoperative pain and opioid use are not commonly concerns if the indication for surgery is not pain related. The same cannot be said for SLAP tears.

National Trends in Use of Regional Anesthesia and Postoperative Patterns of Opioid Prescription Filling in Shoulder Arthroscopy: A Procedure-Specific Analysis in Patients With or Without Recent Opioid Exposure

Background

There are few large database studies on national trends in regional anesthesia for various arthroscopic shoulder procedures and the effect of nerve blocks on the postoperative rate of opioid prescription filling.

Hypothesis

The use of regional nerve block will decrease the rate of opioid prescription filling after various shoulder arthroscopic procedures. Also, the postoperative pattern of opioid prescription filling will be affected by the preoperative opioid prescription-filling history.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patient data from Humana, a large national private insurer, were queried via PearlDiver software, and a retrospective review was conducted from 2007 through 2015. Patients undergoing arthroscopic shoulder procedures were identified through Current Procedural Terminology codes. Nerve blocks were identified by relevant codes for single-shot and indwelling catheter blocks. The blocked and unblocked cases were age and sex matched to compare the pain medication prescription-filling pattern. Postoperative opioid trends (up to 6 months) were compared by regression analysis.

Results

We identified 82,561 cases, of which 54,578 (66.1%) included a peripheral nerve block. Of the patients who received a block, 508 underwent diagnostic shoulder arthroscopy; 2449 had labral repair; 4746 had subacromial decompression procedure; and 12,616 underwent rotator cuff repair. The percentage of patients undergoing a nerve block increased linearly over the 9-year study period (R ² = 0.77; P = .002). After matching across the 2 cohorts, there was an identical trend in opioid prescription filling between blocked and unblocked cases (P = .95). When subdivided by procedure, there was no difference in the trends between blocked and unblocked cases (P = .52 for diagnostic arthroscopies; P = .24 for labral procedures; P = .71 for subacromial decompressions; P = .34 for rotator cuff repairs). However, when preoperative opioid users were isolated, postoperative opioid prescription filling was found to be less common in the first 2 weeks after surgery when a nerve block was given versus not given (P < .001).

Conclusion

An increasing percentage of shoulder arthroscopies are being performed with regional nerve blocks. However, there was no difference in patterns of filled postoperative opioid prescriptions between blocked and unblocked cases, except for the subgroup of patients who had filled an opioid prescription within 1 to 3 months prior to shoulder arthroscopy. Future research should focus on recording the amount of prescribed opioids consumed in national databases to reinforce our strategy against the opioid epidemic.

Rate and Risk Factors Associated With Prolonged Opioid Use After Surgery: A Systematic Review and Meta-analysis

IMPORTANCE

Prolonged opioid use after surgery may be associated with opioid dependency and increased health care use. However, published studies have reported varying estimates of the magnitude of prolonged opioid use and risk factors associated with the transition of patients to long-term opioid use.

OBJECTIVES

To evaluate the rate and characteristics of patient-level risk factors associated with increased risk of prolonged use of opioids after surgery.

DATA SOURCES

For this systematic review and meta-analysis, a search of MEDLINE, Embase, and Google Scholar from inception to August 30, 2017, was performed, with an updated search performed on June 30, 2019. Key words may include opioid analgesics, general surgery, surgical procedures, persistent opioid use, and postoperative pain.

STUDY SELECTION

Of 7534 articles reviewed, 33 studies were included. Studies were included if they involved participants 18 years or older, evaluated opioid use 3 or more months after surgery, and reported the rate and adjusted risk factors associated with prolonged opioid use after surgery.

DATA EXTRACTION AND SYNTHESIS

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed. Two reviewers independently assessed and extracted the relevant data.

MAIN OUTCOMES AND MEASURES

The weighted pooled rate and odds ratios (ORs) of risk factors were calculated using the random-effects model.

RESULTS

The 33 studies included 1 922 743 individuals, with 1 854 006 (96.4%) from the US. In studies with available sex and age information, participants were mostly female (1 031 399; 82.7%) and had a mean (SD) age of 59.3 (12.8) years. The pooled rate of prolonged opioid use after surgery was 6.7% (95% CI, 4.5%-9.8%) but decreased to 1.2% (95% CI, 0.4%-3.9%) in restricted analyses involving only opioid-naive participants at baseline. The risk factors with the strongest associations with prolonged opioid use included preoperative use of opioids (OR, 5.32; 95% CI, 2.94-9.64) or illicit cocaine (OR, 4.34; 95% CI, 1.50-12.58) and a preoperative diagnosis of back pain (OR, 2.05; 95% CI, 1.63-2.58). No significant differences were observed with various study-level factors, including a comparison of major vs minor surgical procedures (pooled rate: 7.0%; 95% CI, 4.9%-9.9% vs 11.1%; 95% CI, 6.0%-19.4%; P = .20). Across all of our analyses, there was substantial variability because of heterogeneity instead of sampling error.

CONCLUSIONS AND RELEVANCE

The findings suggest that prolonged opioid use after surgery may be a substantial burden to public health. It appears that strategies, such as proactively screening for at-risk individuals, should be prioritized.

Editorial Commentary: Hip Preservation and Opioids

Approximately one-third of patients undergoing arthroscopic hip preservation surgery for femoroacetabular impingement syndrome and labral tears are on preoperative opioid medications. The single most important predictor for prolonged chronic postoperative opioid use is preoperative use. Despite the well-documented high success rates in nonarthritic, nondysplastic individuals undergoing hip arthroscopy, up to half of those individuals on preoperative opioids may still be on opioids at 1 to 2 years of follow-up. Mental wellness disorders (e.g., depression, anxiety, substance abuse) significantly impact both pre- and postoperative pain, function, and activity in nearly all joint and general health outcome measures. Multimodal pain management strategies have shown excellent reduction in perioperative opioid utilization. Intraoperative techniques should strive for comprehensive true hip preservation: labral repair, accurate cam/pincer morphology correction, and routine capsular management. Objective, quantitative pain threshold and pain tolerance measurements may improve treatment decision-making, with better prediction of surgical outcomes. Future personalized health care may use a single individual's mu opioid receptor (OPRM-1 gene) and a number of other genetic markers for pain management to reduce the need for traditional opioid medications. Is opioid-free hip arthroscopy possible? Absolutely. Will the opioid epidemic end? Yes, but we have a lot of work to do.

The Effect of Postoperative Opioid Prescription Refills on Achieving Meaningful Clinical Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To determine whether requiring postoperative opioid refills has an effect on both baseline and postoperative functional scores, as well as rates of achieving clinical success 2 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 were analyzed. Patients with at least 1 postoperative opioid refill were matched 1:2 by age and body mass index to patients not requiring refills. Preoperative and postoperative patient-reported outcomes including the Hip Outcome Score-Activities of Daily Living Subscale, HOS-Sports Subscale, and modified Hip Harris Score, as well as visual analog scale (VAS) pain and satisfaction surveys, were compared between the 2 groups, as well as between patients who requested 1 refill versus those requiring 2 or more refills. The minimal clinically important difference and patient acceptable symptomatic state (PASS) were calculated for the study group and compared between patient groups.

RESULTS

A total of 128 patients (14.5%) requesting at least 1 postoperative opioid refill and 256 with no refills were included in the study. Analysis showed that the refill group had lower patient-reported outcomes (P < .05 for all), a lower VAS satisfaction score average (73.2 ± 30.7 vs 80.1 ± 25.9, P = .029), and a higher VAS pain score average (27.2 ± 26.1 vs 19.9 ± 22.7, P = .007). Similar trends were seen when patients with 1 refill were compared with those with 2 or more refills. Analysis of meaningful clinical outcomes showed that patients in the refill group had lower rates of achieving the PASS (68.3% vs 77.2%, P = .006). However, there were no statistically significant differences in achieving the minimal clinically important difference between the 2 groups (P > .05 for all).

CONCLUSIONS

Patients undergoing hip arthroscopy for FAIS who require 1 or more opioid refills postoperatively are likely to have lower baseline and postoperative functional scores, as well as to achieve the PASS at lower rates, compared with patients who do not require an additional opioid prescription to what is routinely given after surgery.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Utility of catastrophizing, body symptom diagram score and history of opioid use to predict future health care utilization after a primary care visit for musculoskeletal pain

BACKGROUND

Self-report information about pain and pain beliefs are often collected during initial consultation for musculoskeletal pain. These data may provide utility beyond the initial encounter, helping provide further insight into prognosis and long-term interactions of the patient with the health system.

OBJECTIVE

The aim of this study was to determine if pain catastrophizing and pain-related body symptoms can predict future health care utilization.

METHODS

This was a longitudinal cohort study. Baseline data were collected after receiving initial care for a musculoskeletal disorder in a multidisciplinary clinic within a large military hospital. Subjects completed the Pain Catastrophizing Scale, a region-specific disability measure, numeric pain rating scale and a body symptom diagram. Health care utilization data for 1 year prior and after the visit were extracted from the Military Health System Data Repository. Multivariable regression models appropriate for skewed and count data were developed to predict (i) musculoskeletal-specific medical visits, (ii) 12-month opioid use, (iii) musculoskeletal-specific medical costs and (iv) total medical costs. We investigated whether a pain catastrophizing × body symptom diagram interaction improved prediction, and developed separate models for opioid-naïve individuals and those with a history of opioid use in an exploratory analysis.

RESULTS

Pain catastrophizing but not body symptom diagram was a significant predictor of musculoskeletal visits, musculoskeletal costs and total medical costs. Exploratory analyses suggest these relationships are most robust for patients with a history of opioid use.

CONCLUSIONS

Pain catastrophizing can identify risk of high health care utilization and costs, even after controlling for common clinical variables. Addressing pain catastrophizing in the primary care setting may help to mitigate future health care utilization and costs, while improving clinical outcomes. These results provide direction for future validation studies in larger and more traditional primary care settings.

Preoperative opioid use is associated with inferior outcomes after patellofemoral stabilization surgery

PURPOSE

The purpose of the study was to investigate the association between preoperative opioid use and persistent postoperative use, and determine the impact of preoperative opioid use on patient-reported outcomes (PROs) in patients undergoing patellofemoral stabilization surgery.

METHODS

A retrospective analysis of 60 patients after patellofemoral stabilization surgery with a minimum of 2-year follow-up was performed using a prospectively collected patellar instability registry. Patients were categorized as opioid naïve (n = 48) or preoperative opioid users (n = 12). Postoperative opioid use was assessed for all patients at 2 and 6 weeks. Knee Injury and Osteoarthritis Outcome Score (KOOS) and Kujala questionnaires were administered at baseline, and 6 months and 2 years postoperatively.

RESULTS

Preoperative opioid use was identified as an independent risk factor for postoperative opioid use at 2- and 6-weeks following surgery (p = 0.0023 and p < 0.0001, respectively). Preoperative opioid use was associated with significantly lower KOOS and Kujala scores at baseline, 6 months and 2 years postoperatively. Both groups significantly improved from baseline KOOS and Kujala scores at 6 months and 2 years postoperatively. Regardless of preoperative opioid use, opioid use at 6 weeks after surgery was associated with worse KOOS scores at 6 months and 2 years postoperatively.

CONCLUSION

In patients undergoing patellofemoral stabilization surgery, preoperative opioid use was predictive of postoperative use. Additionally, preoperative opioid use was associated with worse PROs at 6 months and 2 years following surgery.

LEVEL OF EVIDENCE

III.

Risk factors for opioid use after total shoulder arthroplasty

HYPOTHESIS

The purpose was to assess opioid use before and after anatomic and reverse total shoulder arthroplasty (TSA) and determine patient factors associated with prolonged postoperative opioid use.

METHODS

Patients undergoing primary TSA (anatomic or reverse) were identified within the Humana database from 2007 to 2015. Patients were categorized as opioid-naive patients who did not fill a prescription prior to surgery or those who filled opioid prescriptions within 3 months preoperatively (OU); the OU cohort was subdivided into those filling opioid prescriptions within 1 month preoperatively and those filling opioid prescriptions between 1 and 3 months preoperatively. The incidence of opioid use was evaluated preoperatively and longitudinally tracked for each cohort. Multivariate analysis was used to identify factors associated with opioid use at 12 months after surgery, with statistical significance defined as P < .05.

RESULTS

Overall, 12,038 patients (5180 in OU cohort, 43%) underwent primary TSA during the study period. Opioid use declined after the first postoperative month; however, the incidence of opioid use was significantly higher in the OU cohort than in the opioid-naive cohort at 1 year (31.4% vs. 3.1%, P < .0001). Subgroup analysis revealed a similar decline in postoperative opioid use for anatomic and reverse TSA (P < .0001 for both). Multivariate analysis identified chronic preoperative opioid use (ie, filling an opioid prescription between 1 and 3 months prior to surgery) as the strongest risk factor for opioid use at 12 months after anatomic and reverse TSA (P < .0001).

CONCLUSION

More than 40% of patients undergoing TSA received opioid medications within 3 months before surgery. Preoperative opioid use, age younger than 65 years, and fibromyalgia were independent risk factors for opioid use 1 year following anatomic and reverse TSA. Chronic preoperative opioid use conferred the highest risk of prolonged postoperative opioid use.

Opioids After Arthroscopy: We're Only Halfway Through the Crisis

The orthopaedic community and the general medical community have made progress in the quest to control opioid abuse, but perhaps we are only halfway there. Ample literature has defined the crisis, and governmental guidelines have attempted to curb overprescribing. The American Board of Orthopaedic Surgery now emphasizes the importance of continuing education on the issue, and the arthroscopic and related surgical literature shows the deleterious effect of preoperative narcotic consumption and the opportunity to achieve positive outcomes while limiting postoperative opioid prescriptions. A comprehensive solution requires identifying the problem, considering multimodal anesthesia, avoiding overprescribing, acknowledging that minimizing opioid use is not equivalent to undertreating pain, minimizing preoperative opioid use, managing patient expectations, and continuing to investigate the outcomes of pain management while limiting opioid prescriptions or forgoing opioids altogether.