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Kinder KD, Stambough JB, Barnes CL, Porter A, Mears SC, Stronach BM. Pericapsular Nerve Group Block Did Not Reduce Postoperative Pain or Opioid Use After Total Hip Arthroplasty. J Arthroplasty 2024; 39:S112-S116. [PMID: 39019412 PMCID: PMC11339861 DOI: 10.1016/j.arth.2024.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND The pericapsular nerve group (PENG) block is a newly developed regional anesthesia technique designed to manage postoperative hip pain following a fracture or surgery while also maintaining quadriceps strength and mobility. The goal of our study was to compare postoperative pain scores and opioid usage during the postoperative period before discharge following total hip arthroplasty (THA) using the posterior approach between patients who received a PENG block and those who did not. METHODS We conducted a retrospective study on patients undergoing elective, posterior approach THA at a single tertiary-care academic center. The 2 groups included a study group (THA with PENG block in 2021; n = 66) and a control group (THA before PENG block implementation in 2019; n = 70). RESULTS There were no significant differences in pain scores during postoperative minutes 0 to 59 (study group 6.8; control group 6.6; P = .81) or during postoperative minutes 60 to 119 (study group 6.2; control group 5.6; P = .40). There were no significant differences in total postoperative in-hospital morphine milliequivalent opioid consumption (study group 55.8 morphine milligram equivalents; control group 75.0 morphine milligram equivalents; P = .14). The study group was found to have a shorter length of stay (study group 17.0 hours; control group 32.6 hours; P < .0001) and faster mobilization (study group 3.0 hours; control group 4.9 hours; P < .0001) than the control group. CONCLUSIONS Our results show that use of the PENG block did not result in lower postoperative pain scores or opioid consumption after THA using the posterior surgical approach. The study group had a shorter length of stay and time to mobilization than the control group, though this was likely due to standard hospital procedure shifting to same-day discharge for THA between 2019 and 2021 due to COVID-19.
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Affiliation(s)
- Kathleen D. Kinder
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Jeffrey B. Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - C. Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Austin Porter
- Department of Health Policy & Management, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Benjamin M. Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72202
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Farronato DM, Pezzulo JD, Paulik J, Miltenberg B, Johns WL, Davis DE. The impact of preoperative benzodiazepine use on postoperative opioid use in total shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00222-2. [PMID: 38548094 DOI: 10.1016/j.jse.2024.02.021] [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: 09/07/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND As the rate of total shoulder arthroplasty (TSA) and preoperative benzodiazepine use rise, there is an increased need to understand the impact of preoperative benzodiazepine use on postoperative opioid consumption following TSA, especially amid the current opioid epidemic. The relationship between preoperative benzodiazepine use and chronic opioid use postoperatively has been well described following other orthopedic procedures; however, the impact on patients undergoing TSA remains unclear. This study aims to identify the impact of preoperative benzodiazepine use on opioid use following TSA. METHODS A retrospective chart review of 4488 patients undergoing primary TSA (Current Procedural Terminology code 23472) at a single institution from 2014 to 2022 was performed. Patient demographics, surgical variables, comorbidities, Distressed Communities Index (DCI), and clinical outcomes, including readmission and revision, were collected. The Charlson Comorbidity Index (CCI) was used to assess preoperative health status. Opioid use in morphine milligram equivalents (MMEs) and benzodiazepine use were also recorded using the Prescription Drug Monitoring Program Database. Opioid use was collected at 30-, 60-, and 90-day intervals both before and after each patient's date of surgery. Statistical analysis included stepwise logistic regression to identify variables independently affecting benzodiazepine use pre- and postoperatively. RESULTS Overall, 16% of patients used benzodiazepines within 90 days before their date of surgery. Of those patients, 46.4% were also using preoperative opioids, compared with just 30.0% of patients who were benzodiazepine-naïve (P < .001). Preoperative benzodiazepine use was also associated with increased pre- and postoperative total opioid use in MMEs and the number of opioid prescriptions across all time points when compared to benzodiazepine-naïve patients (P < .001). Furthermore, 37.4% of preoperative benzodiazepine users went on to prolonged opioid use (filled prescriptions >30 days after surgery) compared to 19.0% of those who were benzodiazepine-naïve (P < .001). CONCLUSION This study demonstrates a significant association between preoperative benzodiazepine use and increased and prolonged opioid use following TSA. Further exploration of risk factors contributing to preoperative benzodiazepine use may help to reduce overall opioid use in patients undergoing TSA.
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Affiliation(s)
- Dominic M Farronato
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Pezzulo
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - John Paulik
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin Miltenberg
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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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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MacFarlane AJ, Ritter B, Uffer J, Feng L, Streicher A, Haider MN, Duquin TR. Greater Mental Health Burden is Associated With Poor Postoperative Pain Control and Increased Opioid Utilization Following Total Shoulder Arthroplasty. J Shoulder Elb Arthroplast 2024; 8:24715492231223665. [PMID: 38186672 PMCID: PMC10771065 DOI: 10.1177/24715492231223665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Background Prolonged opioid use is associated with higher complications and worse patient-reported outcomes following total shoulder arthroplasty (TSA). Identified risk factors for prolonged postoperative use are related to several medical comorbidities, gender, diagnoses of anxiety or depressive disorders, and preoperative opioid use. In this study, we hypothesized that patient-reported mental health characteristics can help to identify patients at risk of worse postoperative pain control, worse sleep, and higher opioid utilization following TSA. Methods Ninety-three consecutive patients were asked to fill out 2 mental health questionnaires prior to undergoing TSA. Following surgery, patients filled out a daily pain diary to track their daily pain, pain medication use, and quality and duration of their sleep for 30 days. Preoperative opioid use and postoperative refill were determined by the New York State Prescription Monitoring Program. Mixed-model linear regressions were conducted. Significance was defined as p < 0.05. Results Postoperative opioid refill was associated with female gender, preoperative opioid therapy, higher inpatient opioid use, worse anxiety, depression, somatization, and pain catastrophizing scores. The number of days using opioids postoperatively was associated with worse pain catastrophizing scale (PCS) and somatization scores (patient health questionnaire-15). Preoperative opioid therapy was associated with worse somatization scores, whereas no opioids used after surgery were associated with better somatization scores. Worse sleep quality and duration were associated with worse PCS scores. Conclusion A greater mental health burden is associated with worse postoperative pain control and higher opioid utilization during the acute postoperative period. This is especially evident in the pain catastrophizing and somatization domains.
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Affiliation(s)
| | - Benjamin Ritter
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Joshua Uffer
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Lin Feng
- UBMD Orthopaedics and Sports Medicine, Buffalo, New York
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Pryymachenko Y, Wilson R, Haxby Abbott J, Dowsey M, Choong P. The long-term impacts of opioid use before and after joint arthroplasty: matched cohort analysis of New Zealand linked register data. Fam Pract 2023:cmad112. [PMID: 38052095 DOI: 10.1093/fampra/cmad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Opioids are commonly used both before and after total joint arthroplasty (TJA). OBJECTIVE The objective of this study was to estimate the long-term effects of pre- and perioperative opioid use in patients undergoing TJA. METHODS We used linked population datasets to identify all (n =18,666) patients who had a publicly funded TJA in New Zealand between 2011 and 2013. We used propensity score matching to match individuals who used opioids either before surgery, during hospital stay, or immediately post-discharge with individuals who did not based on a comprehensive set of covariates. Regression analysis was used to estimate the effect of opioid use on health and socio-economic outcomes over 5 years. RESULTS Opioid use in the 3 months prior to surgery was associated with significant increases in healthcare utilization and costs (number of hospitalizations 6%, days spent in hospital 14.4%, opioid scripts dispensed 181%, and total healthcare costs 11%). Also increased were the rate of receiving social benefits (2 percentage points) and the rates of opioid overdose (0.5 percentage points) and mortality (3 percentage points). Opioid use during hospital stay or post-discharge was associated with increased long-term opioid use, but there was little evidence of other adverse effects. CONCLUSIONS Opioid use before TJA is associated with significant negative health and economic consequences and should be limited. This has implications for opioid prescribing in primary care. There is little evidence that peri- or post-operative opioid use is associated with significant long-term detriments.
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Affiliation(s)
- Yana Pryymachenko
- Department of Surgical Sciences, Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand
| | - Ross Wilson
- Department of Surgical Sciences, Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand
| | - John Haxby Abbott
- Department of Surgical Sciences, Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand
| | - Michelle Dowsey
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Peter Choong
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
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Awad ME, Farley BJ, Mostafa G, Darwiche HF, Saleh KJ. The risk of hospital readmission, revision, and intra- and postoperative complications between direct anterior versus posterior approaches in primary total hip arthroplasty: a stratified meta-analysis and a probability based cost projection. Hip Int 2023; 33:442-462. [PMID: 35437055 DOI: 10.1177/11207000211066454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study presents stratified meta-analysis and projected cost per case analysis of direct anterior approach (DAA) versus posterior approach (PA) in total hip arthroplasty (THA) to determine the best surgical approach and guarantee hip joint longevity. METHODS Several online databases were searched for clinical trials comparing DAA and PA in primary THA. The stratified analysis was conducted to test for confounding and biases across the different types of included trials. The average cost and probability were used to determine projected added costs of medical and surgical management for complications. RESULTS 30 clinical trials included 11,562 patients who underwent THA. Almost 50% of these patients performed DAA. As compared to PA, both non-stratified and stratified analyses demonstrated that DAA has a significant higher incidence of the overall intra- and postoperative complications (non-stratified, OR 1.64; p = 0.003) (stratified, OR 4.12; p = 0.005), nerve injury (non-stratified, OR 22.0; p < 0.00001) (stratified, OR 0.28; p < 0.00001), higher rate of revision surgery (non-stratified; OR 1.54; p = 0.01) (stratified, OR 7.37; p = 0.006), and higher incidence of surgical wound complications (non-stratified; OR 1.67; p = 0.002) as compared to PA following primary THA. In addition, DAA demonstrated higher trends of incidence (non-statistically significant) of femur fracture (Non-stratified, OR 1.32, p = 0.10) and thrombo-embolic complications (Retrospective studies, OR 1.39, p = 0.69). However, PA demonstrated higher trends of incidence (non-statistically significant) of hip joint dislocation, as compared to DAA. (Stratified RCTs, OR 0.63, p = 0.65]. Collectively, this amounts a $421,068.68 surplus in DAA complication costs. CONCLUSIONS PA may provide a more lucrative, safer approach to those undergoing THA given its comparable postoperative outcomes, reduced complication rates, and lower overall cost relative to DAA.
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Affiliation(s)
- Mohamed E Awad
- Resident Research Partnership, Detroit, MI, USA
- Michigan State University, College of Osteopathic Medicine, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
| | - Brendan J Farley
- Resident Research Partnership, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
- Central Michigan University, College of Medicine, Mount Pleasant, MI, USA
| | - Gamal Mostafa
- Wayne State University, School of Medicine, Detroit, MI, USA
| | - Hussein F Darwiche
- Department of Orthopedic Surgery, Detroit Medical Center, Detroit, MI, USA
| | - Khaled J Saleh
- Resident Research Partnership, Detroit, MI, USA
- Michigan State University, College of Osteopathic Medicine, Detroit, MI, USA
- FAJR Scientific, Northville, MI, USA
- Central Michigan University, College of Medicine, Mount Pleasant, MI, USA
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van Brug HE, Nelissen RGHH, Rosendaal FR, van Steenbergen LN, van Dorp ELA, Bouvy ML, Dahan A, Gademan MGJ. Out-of-hospital opioid prescriptions after knee and hip arthroplasty: prescribers and the first prescribed opioid. Br J Anaesth 2023; 130:459-467. [PMID: 36858887 DOI: 10.1016/j.bja.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/14/2022] [Accepted: 12/28/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND We determined the first prescribed opioid and the prescribers of opioids after knee and hip arthroplasty (KA/HA) between 2013 and 2018 in the Netherlands. We also evaluated whether the first prescribed opioid dose was associated with the total dispensed dose and long-term opioid use in the first postoperative year. METHODS The Dutch Foundation for Pharmaceutical Statistics was linked to the Dutch Arthroplasty Register. Stratified for KA/HA, the first out-of-hospital opioid within 30 days of operation was quantified as median morphine milligram equivalent (MME). Opioid prescribers were orthopaedic surgeons, general practitioners, rheumatologists, anaesthesiologists, and other physicians. Long-term use was defined as ≥1 opioid prescription for >90 postoperative days. We used linear and logistic regression analyses adjusted for confounders. RESULTS Seventy percent of 46 106 KAs and 51% of the 42 893 HAs were prescribed ≥1 opioid. Oxycodone increased as first prescribed opioid (from 44% to 85%) whereas tramadol decreased (64-11%), but their dosage remained stable (stronger opioids were preferred by prescribers). An increase in the first prescription of 1% MME resulted in a 0.43%/0.37% increase in total MME (KA/HA, respectively). A 100 MME increase in dose of the first dispensed opioid had a small effect on long-term use (prevalence: 25% KA, 20% HA) (odds ratio=1.02/1.01 for KA/HA, respectively). Orthopaedic surgeons increasingly prescribed the first prescription between 2013 and 2018 (44-69%). General practitioners mostly prescribed consecutive prescriptions (>50%). CONCLUSION Oxycodone increased as first out-of-hospital prescription between 2013 and 2018. The dose of the first prescribed opioid was associated with the total dose and a small increased risk of prolonged use. First prescriptions were mostly written by orthopaedic surgeons and consecutive prescriptions by general practitioners.
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Affiliation(s)
- Heather E van Brug
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands; Dutch Arthroplasty Register (LROI), s-Hertogenbosch, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Eveline L A van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marcel L Bouvy
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maaike G J Gademan
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Bakewell BK, Townsend CB, Ly JA, Sherman M, Abdelfattah HM, Solarz M, Woozley K, Ilyas AM. The Effect of Preoperative Benzodiazepine Usage on Postoperative Opioid Consumption After Hand Surgery: A Multicenter Analysis. Cureus 2022; 14:e29609. [PMID: 36321037 PMCID: PMC9601921 DOI: 10.7759/cureus.29609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/01/2022] Open
Abstract
Background Prescription rates of opioids and benzodiazepines have steadily increased in the last decade with the percentage of prescription opioid overdose deaths involving benzodiazepines more than doubling during that time. Orthopaedic surgery is one of the highest-volume opioid prescribing medical specialties, but the effects of benzodiazepine use on orthopaedic surgery patient outcomes are not well understood. The purpose of the study was to utilize the state Prescription Drug Monitoring Program (PDMP) database to investigate if perioperative benzodiazepine use predisposes patients to prolonged opioid use following hand and upper extremity orthopaedic surgery. Methods This study was retrospective and conducted at three urban academic institutions. All patients who underwent carpal tunnel release, thumb basal joint arthroplasty, and distal radius fracture open reduction internal fixation performed by 14 board-certified, fellowship-trained orthopaedic hand and upper extremity surgeons between April 2018 and August 2019, were collected via a database query. All opioid and benzodiazepine prescriptions were collected from three months preoperatively to six months postoperatively. Results In this study, 634 patients met the inclusion criteria presented to one of the three institutions during the 18-month study period. Patients consisted of 276 carpal tunnel releases, 217 distal radius fracture open reduction internal fixations, and 141 thumb basal joint arthroplasties. Benzodiazepine users were 14.6% more likely to fill an additional opioid prescription (p<0.005) and were 10.8% more likely to experience prolonged three to six-month postoperative opioid use (p<0.005). Conclusion This study found that patients who use benzodiazepines are at a higher risk of filling additional opioid prescriptions and prolonged opioid use following hand and upper extremity surgery. Prescribers should take this into account when prescribing opioids after upper extremity orthopaedic surgery.
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Hereford TE, Porter A, Stambough JB, Cherney SM, Mears SC. Prevalence of Chronic Opioid Use in the Elderly After Hip Fracture Surgery. J Arthroplasty 2022; 37:S530-S535. [PMID: 35219575 DOI: 10.1016/j.arth.2022.01.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/18/2022] [Accepted: 01/24/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND While interest has focused on opioid use after total hip arthroplasty, little research has investigated opioid use in elderly patients after hip fracture. We hypothesize that a substantial number of opioid-naïve elderly patients go on to chronic opioid use after hip fracture surgery. METHODS We reviewed a consecutive series of 219 patients 65 years and older who underwent surgical fixation between January 1, 2016 and February 28, 2019 for a native hip fracture. Patients were excluded for polytrauma, periprosthetic or pathologic fractures, recent major surgery, or death within 90 days of their hip surgery. The state prescription monitoring database was used to determine opioid use. RESULTS Overall, 58 patients (26%) were postoperative chronic opioid users. Of the initial 188 opioid-naïve patients, 43 (23%) became chronic users. Of the 31 preoperative opioid users, 15 (48%) continued as chronic users. Chronic postoperative users were more likely to be White (76% vs 91%, P = .04), younger (78 vs 82 years, P = .003), and preoperative opioid users (odds ratio 3.3, P = .007). Arthroplasty vs fixation did not affect the rate of chronic opioid use (P = .22). CONCLUSION Chronic opioid use is surprisingly common after hip fracture repair in the elderly. Twenty-three percent of opioid-naïve hip fracture patients became chronic users after surgery. Continued vigilance is needed by orthopedic surgeons to limit the amount and duration of postoperative narcotic prescriptions and to monitor for continued use.
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Affiliation(s)
- Timothy E Hereford
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Austin Porter
- Fay W. Boozman College of Public Health, Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR; Arkansas Department of Health, Little Rock, AR
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Steven M Cherney
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
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Berardino K, Carroll AH, Popovsky D, Ricotti R, Civilette MD, Sherman WF, Kaye AD. Opioid Use Consequences, Governmental Strategies, and Alternative Pain Control Techniques Following Total Hip Arthroplasties. Orthop Rev (Pavia) 2022; 14:35318. [DOI: 10.52965/001c.35318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/11/2022] [Indexed: 11/06/2022] Open
Abstract
Over the last several decades, rates of opioid use and associated problems have dramatically increased in the United States leading to laws limiting prescription duration for acute pain management. As a result, orthopedic surgeons who perform total hip arthroplasty (THA), a procedure that often leads to significant postoperative pain, have been faced with substantial challenges to adequately mitigate patient pain while also reducing opioid intake. Current strategies include identifying and correcting modifiable risk factors associated with postoperative opioid use such as preoperative opioid use, alcohol and tobacco abuse, and untreated psychiatric illness. Additionally, recent evidence has emerged in the form of Enhanced Recovery After Surgery (ERAS) protocols suggesting that a multidisciplinary focus on patient factors perioperatively can lead to reduced postoperative opioid administration and decreased hospital stays. A cornerstone of ERAS protocols includes multimodal pain regimens with opioid rescue only as needed, which often includes multiple systemic pain therapies such as acetaminophen, gabapentin, non-steroidal anti-inflammatory drugs, as well as targeted pain therapies that include epidural catheters and ultrasound-guided nerve blocks. Many hospital systems and states have also implemented opioid prescribing limitations with mixed success. As the opioid epidemic continues in the United States, while contributing to poor outcomes following elective surgeries, further research is warranted to identify multidisciplinary strategies that mitigate opioid use while also allowing for adequate pain control and rehabilitation.
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Gabriel RA, Harjai B, Prasad RS, Simpson S, Chu I, Fisch KM, Said ET. Machine learning approach to predicting persistent opioid use following lower extremity joint arthroplasty. Reg Anesth Pain Med 2022; 47:313-319. [PMID: 35115414 PMCID: PMC8961772 DOI: 10.1136/rapm-2021-103299] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/18/2022] [Indexed: 12/27/2022]
Abstract
Background The objective of this study is to develop predictive models for persistent opioid use following lower extremity joint arthroplasty and determine if ensemble learning and an oversampling technique may improve model performance. Methods We compared various predictive models to identify at-risk patients for persistent postoperative opioid use using various preoperative, intraoperative, and postoperative data, including surgical procedure, patient demographics/characteristics, past surgical history, opioid use history, comorbidities, lifestyle habits, anesthesia details, and postoperative hospital course. Six classification models were evaluated: logistic regression, random forest classifier, simple-feedforward neural network, balanced random forest classifier, balanced bagging classifier, and support vector classifier. Performance with Synthetic Minority Oversampling Technique (SMOTE) was also evaluated. Repeated stratified k-fold cross-validation was implemented to calculate F1-scores and area under the receiver operating characteristics curve (AUC). Results There were 1042 patients undergoing elective knee or hip arthroplasty in which 242 (23.2%) reported persistent opioid use. Without SMOTE, the logistic regression model has an F1 score of 0.47 and an AUC of 0.79. All ensemble methods performed better, with the balanced bagging classifier having an F1 score of 0.80 and an AUC of 0.94. SMOTE improved performance of all models based on F1 score. Specifically, performance of the balanced bagging classifier improved to an F1 score of 0.84 and an AUC of 0.96. The features with the highest importance in the balanced bagging model were postoperative day 1 opioid use, body mass index, age, preoperative opioid use, prescribed opioids at discharge, and hospital length of stay. Conclusions Ensemble learning can dramatically improve predictive models for persistent opioid use. Accurate and early identification of high-risk patients can play a role in clinical decision making and early optimization with personalized interventions.
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Affiliation(s)
- Rodney A Gabriel
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Bhavya Harjai
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Rupa S Prasad
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Sierra Simpson
- Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Iris Chu
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Kathleen M Fisch
- Center for Computational Biology and Bioinformatics, University of California San Diego, La Jolla, California, USA
| | - Engy T Said
- Anesthesiology, University of California San Diego, La Jolla, California, USA
- University of California San Diego, San Diego, California, USA
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12
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Cao G, Xiang S, Yang M, Quan S, Yao J, Cai L, Feng W, Yang X, Xu H, Huang Z, Zhang S, Yue C, Tan H, Pei F. Risk factors of opioid use associated with an enhanced-recovery programme after total knee arthroplasty. BMC Musculoskelet Disord 2021; 22:1046. [PMID: 34930202 PMCID: PMC8690997 DOI: 10.1186/s12891-021-04937-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 12/03/2021] [Indexed: 02/08/2023] Open
Abstract
Background Characterizing the impacts of postoperative opioid use on total knee arthroplasty (TKA) patients may help optimize the pain management after TKA. The aim of the study is to examine the prevalence and risk factors for opioid use with an enhanced-recovery programme after primary TKA. Methods We identified 361 patients undergoing TKA, and separated those on the basis of whether to receive opioid use after surgery. Themultivariate logistic regression model was used to identify independent risk factors for opioid use after primary TKA. Length of stay (LOS) and postoperative complications were also recorded and compared. Results The prevalence of opioid use after primary TKA was 23.0%. The significant risk factor was the longer operative time (OR [odds ratio] = 1.017, 95% CI [confidence interval] = 1.001 to 1.032, p = 0.034) and the protective factor was the utilization of tranexamic acid(OR= 0.355, 95% CI = 0.161 to 0.780, p = 0.010). In addition, the LOS was longer in opioid group (p < 0.05). Conclusion Considering the adverse health effects of opioid use, strategies need to be developed to prevent persistent opioid use after TKA. Reducing operative time and the application of tranexamic acid could lower the risk of opioid use with an enhanced-recovery programme after primary TKA.
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Affiliation(s)
- Guorui Cao
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Shiqi Xiang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, People's Republic of China
| | - Minglu Yang
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Songtao Quan
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Junna Yao
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Litao Cai
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Wei Feng
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Xiuli Yang
- Department of Orthopaedic surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Hong Xu
- Department of Orthopaedic surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Zeyu Huang
- Department of Orthopaedic surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, People's Republic of China
| | - Chen Yue
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Honglue Tan
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China.
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Beck EC, Nwachukwu BU, Drager J, Jan K, Rasio J, Krishnamoorthy VP, Nho SJ. Prolonged Postoperative Opioid Use After Arthroscopic Femoroacetabular Impingement Syndrome Surgery: Predictors and Outcomes at Minimum 2-Year Follow-up. Orthop J Sports Med 2021; 9:23259671211038933. [PMID: 34888387 PMCID: PMC8649101 DOI: 10.1177/23259671211038933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/04/2021] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Edward C Beck
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Benedict U Nwachukwu
- Division of Sports Medicine Surgery, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Justin Drager
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kyleen Jan
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jonathan Rasio
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Vignesh P Krishnamoorthy
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Preoperative and Postoperative Opioid Prescription Rates in the Total Hip Replacement Surgical Patient. Orthop Nurs 2021; 40:366-374. [PMID: 34851880 DOI: 10.1097/nor.0000000000000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The United States is facing an opioid epidemic that has only worsened with the COVID-19 pandemic. There is little evidence regarding patterns of opioid use among patients with total hip replacement (THR). Although the Centers for Disease Control and Prevention has put forward guidelines for prescribing opioids, it does not include guidance specifically for THR patients suffering from presurgical and postsurgical pain. The purpose of this study was to (1) compare presurgical and postsurgical opioid rates, (2) compare presurgical and postsurgical morphine milligram equivalents (MME), and (3) determine whether having a presurgical opioid prescription predicts the receipt of postsurgical opioid prescriptions among patients undergoing THR surgery. Retrospective cohort analysis of 4,405 patients undergoing THR at a major academic medical center in the United States from April 30, 2015, to April 30, 2018, was done. Patient characteristics, opioid rates, and average MME/day/person were described. Logistic regression was used to determine whether presurgical opioid prescription and opioid risk level predicted postsurgical opioid prescribing. Median age was 64 years (range = 18-85 years); patients were primarily Caucasian/White (78.8%) and female (54.7%). Opioid prescription rates in this sample for the 12-month presurgical and postsurgical periods were 66.1% and 95.6%, respectively. Oxycodone was the most common opioid prescribed in both periods. Among those prescribed an opioid, moderate/high risk for overdose and/or death was 6.3% presurgery and 19.8% postsurgery. Patients with a comorbidity were two times more likely to receive an opioid prescription in the postsurgical period. The median average MME/day/person was 26.5 (range = 0.3-180.0) for patients with an opioid prescribed during the presurgery period and 40.4 (range = 1.5-270.0) during the postsurgery period. Opioid use, regardless of strength, in the presurgical period as well as having one or more comorbidities predicted opioid use in the postsurgical period.
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15
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Comparison of opioid prescribing upon hospital discharge in patients receiving tapentadol versus oxycodone following orthopaedic surgery. Int J Clin Pharm 2021; 43:1602-1608. [PMID: 34089144 DOI: 10.1007/s11096-021-01290-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
Background The changing of opioids during the transition of care from hospital to home may be associated with harm. Objective To compare patients receiving tapentadol IR versus oxycodone IR following orthopaedic surgery during hospitalisation with regard to the changing of opioids at hospital discharge. Setting A major metropolitan tertiary referral hospital in Australia. Methods This is a retrospective cohort study. Participants included adult orthopaedic surgery patients receiving postoperative tapentadol IR or oxycodone IR during hospitalisation between 1 January 2018 and 30 June 2019. Main outcome measure The proportion of patients for whom the opioid prescribed was changed at hospital discharge. Results The study cohort included 199 patients. Of these, 100 patients received oxycodone and 99 patients received tapentadol post-operatively during hospitalisation. The mean age was 66 years (SD, 12 years) and 111 (56%) were female. The most common surgeries were total knee arthroplasty (91, 46%), total hip arthroplasty (63, 32%) and shoulder surgery (26, 13%). Patients in the tapentadol group were more likely to be changed to a different opioid upon hospital discharge than the oxycodone group (57% versus 9%, difference 48% [95% CI 36-59%, p < 0.01). After adjusting for confounders, post-operative tapentadol use was more likely to be associated with opioid changing upon discharge (OR 16.5, 95% CI 6.7 to 40.8, p < 0.01). Conclusions The post-operative use of tapentadol IR during hospitalisation was associated with an increased likelihood of opioid changing at hospital discharge. This practice could have patient safety implications.
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Kulsirirat T, Sathirakul K, Kamei N, Takeda-Morishita M. The in vitro and in vivo study of novel formulation of andrographolide PLGA nanoparticle embedded into gelatin-based hydrogel to prolong delivery and extend residence time in joint. Int J Pharm 2021; 602:120618. [PMID: 33887393 DOI: 10.1016/j.ijpharm.2021.120618] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/06/2021] [Accepted: 04/15/2021] [Indexed: 01/05/2023]
Abstract
Andrographolide (AG), a well-known traditional medicinal plant in Southeast Asia, is widely used for treatment of many chronic diseases. Interestingly, AG has been reported to have inhibitory effects on osteoclast function and anti-inflammatory properties. Because of these therapeutic properties, this study aimed to develop and optimize the formulation of AG using PLGA nanocarriers and gelatin-based hydrogel to prolong the retention time in the joint. We investigated the in vitro release pattern of the AG nanoparticles formulation which prepared by emulsion solvent evaporation method and embedded into gelatin-based hydrogel. The result showed that the AG loaded ester terminated end group PLGA polymer gradually released AG from the PLGA nanoparticles when compared with AG solution. Importantly, the combined use of gelatin-based hydrogel with AG from the PLGA nanoparticles significantly delayed the AG release more than 1 month. Furthermore, we selected the DiR fluorescence dye to represents AG and monitored the retention time by IVIS imaging. The optimal formulation was administered as intra-articular drug delivery systems in in vivo study. The results successfully displayed a long-term sustained release for implantation (≈2 months) and injection (≥2 months) providing a novel strategy for the local management of osteoarthritis disease.
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Affiliation(s)
- Thitianan Kulsirirat
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Korbtham Sathirakul
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Noriyasu Kamei
- Laboratory of Drug Delivery Systems, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe, Hyogo 650-8586, Japan
| | - Mariko Takeda-Morishita
- Laboratory of Drug Delivery Systems, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe, Hyogo 650-8586, Japan.
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Singh A, Chan PH, Prentice HA, Rao AG. Postoperative opioid utilization associated with revision risk following primary shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:1034-1041. [PMID: 32871267 DOI: 10.1016/j.jse.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/05/2020] [Accepted: 08/10/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION With a substantial increase in utilization of primary shoulder arthroplasty, it is important to understand risk factors that may signal early failure and need for revision. Recent studies have reported that sustained postoperative opioid use is associated with a higher revision risk after total hip or knee arthroplasty. In this study, we evaluated postoperative opioid utilization as a risk factor for revision after primary shoulder arthroplasty. METHODS We conducted a cohort study using data from a United States integrated health care system's Shoulder Arthroplasty Registry. Patients who had a primary elective shoulder arthroplasty were identified (2009-2017); those with cancer or who underwent other arthroplasty procedures (either shoulder, hip, or knee) within the preceding year were excluded. Cumulative daily opioid utilization during the first year postoperative, calculated as oral morphine equivalents (OME), was categorized into 3 exposure groups: high user (≥15 mg OME daily), moderate user (<15 mg OME daily), and no opioid use (reference group). The exposure window was stratified into 2 time periods: postoperative days 1-90 and postoperative days 91-360. Multivariable Cox proportional-hazards regression was used to evaluate the association between postoperative opioid use and aseptic revision risk. RESULTS The final study sample included 8325 shoulder arthroplasty procedures. Of these individuals, 3707 (45%) received some opioid within the 1 year before the index procedure. We failed to observe a difference in aseptic revision risk between opioid utilization in the first 90 days postoperatively, regardless of dose. After the first 90 days, a higher revision risk was observed for high opioid users compared with nonusers (hazard ratio = 1.62, 95% confidence interval = 1.10-2.41), and no association was observed for moderate users (hazard ratio = 1.25, 95% confidence interval = 0.82-1.91). CONCLUSIONS We found a positive association between opioid consumption and aseptic revision risk after primary shoulder arthroplasty. This study cannot determine if opioids have a direct physiological cause that increases the risk of revision; rather it is likely that opioid consumption is a marker of chronic pain, poor function, and/or poor coping mechanisms. Further study is needed to determine if programs designed to decrease opioid use may impact revision risk after shoulder arthroplasty.
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Affiliation(s)
- Anshuman Singh
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, CA, USA.
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | | | - Anita G Rao
- Department of Orthopaedics, Northwest Permanente Medical Group, Portland, OR, USA
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Hinther A, Rasool A, Nakoneshny SC, Chandarana SP, Hart R, Matthews TW, Dort JC. Chronic opioid use following surgery for head and neck cancer patients undergoing free flap reconstruction. J Otolaryngol Head Neck Surg 2021; 50:28. [PMID: 33892825 PMCID: PMC8066487 DOI: 10.1186/s40463-021-00508-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 03/08/2021] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Physician opioid-prescribing patterns have significant impacts on the current opioid crisis. Patients who use opioids in the postoperative period are at risk of developing chronic postoperative opioid use. This study determined the rate of chronic postoperative opioid use among head and neck cancer patients undergoing primary surgery with free-flap reconstruction. Additionally, this study identified major risk factors associated with the development of chronic postoperative opioid use. METHODS A retrospective chart review was performed for all adults (age ≥ 18 years) undergoing primary head and neck surgical resection with free-flap reconstruction between January 2008 and December 2015. Patients were identified from a prospectively collected database, Otobase™. Data from the provincial drug insurance program were used to capture drug dispensing information to determine chronic opioid use at 3- and 12-months postoperatively. Data extracted from Otobase™ included patient demographics, social habits, clinical stage, pathological stage, type of surgery, and adjuvant treatment. RESULTS The total cohort was comprised of 212 patients. Chronic opioid use at 3- and 12- months postoperatively was observed in 136 (64%) and 116 (55%) patients, respectively. Of the 212 patients, 85 patients (40%) were identified as preoperative opioid users and 127 were opioid naïve (60%). Of the 85 patients who were preoperative opioid users, 70 (82%) and 63 (77%) patients continued to use opioids 3- and 12-months postoperatively, respectively. The proportion of opioid-naïve patients who were using opioids at 3- and 12-months postoperatively was 52% (66 patients) and 42% (53 patients), respectively. Identified risk factors included preoperative opioid use, prior tobacco use, advanced pathologic T-stage, and adjuvant treatment. CONCLUSIONS Among head and neck cancer patients that have undergone major resection with free-flap reconstruction, the prevalence of chronic postoperative opioid users was considerable. Identified risk factors included preoperative opioid use, prior tobacco use, tumor stage, and adjuvant treatment.
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Affiliation(s)
- Ashley Hinther
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Alysha Rasool
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Steven C Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shamir P Chandarana
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert Hart
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - T Wayne Matthews
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph C Dort
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada.
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Cha Y, Jang SY, Yoo JI, Choi HG, Hwang JW, Choy W. Effect of Opioids on All-cause Mortality and Opioid Addiction in Total Hip Arthroplasty: a Korea Nationwide Cohort Study. J Korean Med Sci 2021; 36:e87. [PMID: 33821594 PMCID: PMC8021974 DOI: 10.3346/jkms.2021.36.e87] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/14/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate the use of opioids before and after total hip arthroplasty (THA), to find out the effect of opioid use on mortality in patients with THA, and to analyze whether preoperative opioid use is a risk factor for sustained opioid use after surgery using Korean nationwide cohort data. METHODS This retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Sample cohort (NHIS-Sample) compiled by the Korean NHIS. The index date (time zero) was defined as 90 days after an admission to a hospital to fulfill the eligibility criteria of the THA. RESULTS In the comparison of death risk according to current use and the defined daily dose of tramadol and strong opioids in each patient group according to past opioid use, there were no statistically significant differences in the adjusted hazard ratio for death compared to the current non-users in all groups (P > 0.05). Past tramadol and strong opioid use in current users increased the risk of the sustained use of tramadol and strong opioids 1.45-fold (adjusted rate ratio [aRR]; 95% confidence interval [CI], 1.12-1.87; P = 0.004) and 1.65-fold (aRR; 95% CI, 1.43-1.91; P < 0.001), respectively, compared to past non-users. CONCLUSION In THA patients, the use of opioids within 6 months before surgery and within 3 months after surgery does not affect postoperative mortality, but a past-use history of opioid is a risk factor for sustained opioid use. Even after THA, the use of strong opioids is observed to increase compared to before surgery.
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Affiliation(s)
- Yonghan Cha
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Suk Yong Jang
- Department of Preventive Medicine, Eulji University College of Medicine, Daejeon, Korea
| | - Jun Il Yoo
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea.
| | - Hyo Gil Choi
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Jeong Won Hwang
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Wonsik Choy
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
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Rife T, Tat C, Malakootian M. Evaluation of an opioid risk mitigation initiative for veterans undergoing hip or knee arthroplasty at San Francisco Veterans Affairs Health Care System. Am J Health Syst Pharm 2020; 78:336-344. [PMID: 33354703 DOI: 10.1093/ajhp/zxaa406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Guidelines recommend evaluating the risk of opioid-related adverse events prior to initiating opioid therapy. The orthopedic service at San Francisco Veterans Affairs Health Care System (SFVHCS) has not routinely used risk assessment tools such as the Stratification Tool for Opioid Risk Mitigation, prescription drug monitoring program data, and urine drug screening prior to opioid prescribing. A quality improvement project was conducted to evaluate the number of pharmacist-provided opioid risk mitigation recommendations implemented by orthopedic providers for patients who underwent total hip or knee arthroplasty at SFVHCS. SUMMARY A pharmacist-led workflow for completing risk mitigation reviews was developed in collaboration with orthopedic providers, and urine drug screening was added to the preoperative laboratory testing protocol. The following recommendations were communicated via electronic medical record: limit postoperative opioids to a 7- or 14-day supply based on risk of suicide and/or overdose, offer naloxone and a medication disposal bag, and order a urine drug screen if not already completed. Risk reviews were completed for 75 patients. Among 64 patients with 2-month postdischarge data available, 88% (7 of 8) of 7-day and 79% (44 of 56) of 14-day opioid supply recommendations were implemented; 41% (26 of 59) of recommendations to issue a medication disposal bag, 17% (2 of 12) recommendations to order a missing urine drug screen, and 9% (5 of 55) of recommendations to offer naloxone were implemented. CONCLUSION Pharmacist-performed risk mitigation reviews paired with individualized recommendations led to high rates of orthopedic provider acceptance of limiting postdischarge opioid day supplies for patients who had total hip or knee arthroplasty. Alternative strategies may increase access to naloxone. Future research should examine the impact of risk mitigation tools in reducing prescribing of long-term opioid therapy and adverse events among orthopedic surgical patients.
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Affiliation(s)
- Tessa Rife
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,University of California, San Francisco, School of Pharmacy, San Francisco, CA
| | - Christina Tat
- San Francisco Veterans Affairs Health Care System, San Francisco, CA.,University of California, San Francisco, School of Pharmacy, San Francisco, CA
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21
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Goldman AH, Griffis CE, Johnson DD, Balazs GC. Shifts in Prescribers' Initial Postoperative Opioid Prescriptions Following Primary Total Hip Arthroplasty Between 2014 and 2018. J Arthroplasty 2020; 35:3208-3213. [PMID: 32622716 DOI: 10.1016/j.arth.2020.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The opioid epidemic is a public health crisis impacting the practice of surgeons performing primary total hip arthroplasty (THA). Seeking to evaluate changes in prescribers' practices, we asked the following questions: (1) Have the initial discharge opioids following THA changed and (2) Have initial total oral morphine milligram equivalents (OME) prescribed following THA decreased since 2014? METHODS We retrospectively reviewed discharge prescriptions for 4233 primary THAs performed between fiscal years (FYs) 2014 and 2018 throughout our healthcare system. Drug, dosing, and total OMEs were recorded. We categorized prescriptions into 3 groups: short-acting narcotics only, short-acting plus long-acting narcotics, and short-acting narcotics plus tramadol. Mean age was 59 and 63% were males. RESULTS The proportion of patients receiving tramadol increased from 2% (FY14) to 25% (FY18) while long-acting opioid prescriptions decreased from 44% (FY14) to 14% (FY18). Oxycodone (82%) was the most common short-acting narcotic. In total, we observed a 27% decrease in initial OME prescribed to a mean of 683 mg (FY18) (P < .0001). Short-acting only protocols had a 19% OME decrease to 589 mg (FY18). Short plus long-acting protocols haed a 23% OME decrease to 939 mg (FY18). Short-acting plus tramadol had an OME of 849 mg (FY18). CONCLUSION Despite a 27% observed decrease in initial OME prescription following THA, the 683 mg mean OME in FY18 was high. Substituting tramadol for a long-acting narcotic failed to have a dramatic clinical impact on decreasing OME. These data suggest that decreasing the number of short-acting narcotic pills is a critical factor in decreasing OME.
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Affiliation(s)
- Ashton H Goldman
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Clare E Griffis
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Daniel D Johnson
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| | - George C Balazs
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
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Bernstein JA, Feng J, Mahure SA, Schwarzkopf R, Long WJ. Revision total hip arthroplasty is associated with significantly higher opioid consumption as compared to primary total hip arthroplasty in the acute postoperative period. Hip Int 2020; 30:59-63. [PMID: 32907423 DOI: 10.1177/1120700020938324] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are currently a lack of investigations that characterised narcotic utilisation following revision total hip arthroplasty (THA). We sought to determine if immediate post-surgical opioid use was different between revision THA and primary THA. METHODS A single institution total joint arthroplasty database was used to identify adult patients who underwent revision THA or primary THA from 2016 to 2019. Morphine milligram equivalents (MME) were calculated for different time periods. RESULTS 6977 patients were identified, 89.72% primary THA and 10.28% revision THA. Aggregate opioid consumption was higher for revision THA patients (317.40 MME vs. 93.01 MME), as was opioid consumption in the first 24 hour and second 24-hour periods. Visual analogue pain (VAS) scores were significantly higher in the 0-12 hour postoperative and the 12-24 hours postoperative periods in the revision THA group. CONCLUSIONS Patients undergoing revision THA had significantly higher narcotic utilisation than those undergoing primary THA, particularly in the first 24 hours postoperatively.
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Affiliation(s)
- Jenna A Bernstein
- Division of Orthopedics - Adult Joint Reconstruction, NYU Langone, New York, NY, USA
| | - James Feng
- Division of Orthopedics - Adult Joint Reconstruction, NYU Langone, New York, NY, USA
| | - Siddharth A Mahure
- Division of Orthopedics - Adult Joint Reconstruction, NYU Langone, New York, NY, USA
| | - Ran Schwarzkopf
- Division of Orthopedics - Adult Joint Reconstruction, NYU Langone, New York, NY, USA
| | - William J Long
- Division of Orthopedics - Adult Joint Reconstruction, NYU Langone, New York, NY, USA.,Insall-Scott-Kelly Institute, New York, NY, USA
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23
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Dattilo JR, Cororaton AD, Gargiulo JM, McDonald JF, Ho H, Hamilton WG. Narcotic Consumption in Opioid-Naïve Patients Undergoing Total Hip and Knee Arthroplasty. J Arthroplasty 2020; 35:2392-2396. [PMID: 32451281 DOI: 10.1016/j.arth.2020.04.089] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/23/2020] [Accepted: 04/26/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with increased risk of prolonged narcotic requirement compared to total hip arthroplasty (THA). This study aims to compare acute postoperative narcotic consumption between the 2 procedures and quantify amount of narcotics used by opioid prescribed. METHODS From October 2017 to August 2019, patients were surveyed at 4-week follow-up to determine amount and duration of opioids used and whether they continued to require narcotics. Among 1332 patients who self-identified as opioid naïve, 670 underwent THA and 662 underwent TKA. Descriptive analysis was performed based on data type. RESULTS The total morphine equivalent dose (MED) used in the postoperative period was lower in THA than in TKA (143 ± 160 vs 259 ± 250 MED, P < .001). The duration of use was shorter, total amount of pills consumed was lower, and refill rates were less in THA compared to TKA regardless of which opioid was prescribed. A smaller proportion of patients required narcotics at 4-week follow-up in THA compared to TKA. A postoperative prescription of 45 pills of any one type of narcotic was sufficient for nearly 90% of THA patients, and 60 pills of any one type of narcotic was appropriate for over 75% of TKA patients. CONCLUSION THA is associated with less total narcotic consumption, shorter duration of use, less refills, and lower likelihood of requiring narcotics at 4-week follow-up. Percentiles of total narcotics consumed are provided to promote judicious postoperative prescribing patterns, and one could consider further reducing narcotics when utilizing our protocol, particularly for THA patients. LEVEL OF EVIDENCE This is a level III retrospective cohort study reviewing narcotic use in over 900 consecutive opioid-naïve patients undergoing total hip and knee arthroplasty.
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Affiliation(s)
| | | | | | | | - Henry Ho
- Anderson Orthopaedic Research Institute, Alexandria, VA
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24
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Deen JT, Stone WZ, Gray CF, Prieto HA, Iams DA, Boezaart AP, Parvataneni HK. A Simple, Personalized Opioid Stratification Pathway Dramatically Reduces Opioid Utilization. Arthroplast Today 2020; 6:731-735. [PMID: 32923559 PMCID: PMC7475051 DOI: 10.1016/j.artd.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/09/2020] [Accepted: 07/09/2020] [Indexed: 11/12/2022] Open
Abstract
Orthopaedic surgeons account for the largest proportion of opioid prescriptions in the United States among surgical specialties. In total joint arthroplasty, increased opioid use has been associated with poorer clinical and functional outcomes. Despite an abundance of literature on opioid mitigation strategies, most fail to provide personalized prescriptions. Typically, most protocols prescribe the same opioid regimen regardless of patient factors or the extent of the planned procedure. We present a simple opioid stratification pathway that can be used by physicians and office staff as they prepare patients for arthroplasty. We have found this to be easy to implement, effective, and sustainable at a tertiary academic institution and allows for iterative improvements over time.
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Affiliation(s)
- Justin T Deen
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - William Z Stone
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Chancellor F Gray
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Hernan A Prieto
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dane A Iams
- Department of Orthopedic Surgery, Denver Health, Denver, CO, USA
| | - Andre P Boezaart
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Hari K Parvataneni
- Department of Orthopedic Surgery and Rehabilitation, University of Florida College of Medicine, Gainesville, FL, USA
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25
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Gause TM, Nunnery JJ, Chhabra AB, Werner BC. Perioperative Narcotic Use and Carpal Tunnel Release: Trends, Risk Factors, and Complications. Hand (N Y) 2020; 15:234-242. [PMID: 30067126 PMCID: PMC7076616 DOI: 10.1177/1558944718792276] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background: The goals of the study were to: (1) evaluate trends in preoperative and prolonged postoperative narcotic use in carpal tunnel release (CTR); (2) characterize risks for prolonged narcotic use; and (3) evaluate narcotic use as an independent risk factor for complications following CTR. Methods: A query of a large insurance database from 2007-2016 was conducted. Patients undergoing open or endoscopic CTR were included. Revision surgeries or patients undergoing median nerve repair at the forearm, upper extremity fasciotomies, or with distal radius fractures were excluded. Preoperative use was defined as narcotic use between 1 to 4 months prior to CTR. A narcotic prescription between 1 and 4 months after surgery was considered prolonged postoperative use. Demographics, comorbidities, and other risk factors for prolonged postoperative use were assessed using a regression analysis. Subgroup analysis was performed according to the number of preoperative narcotic prescriptions. Narcotic use as a risk factor for complications, including chronic regional pain syndrome (CRPS) and revision CTR, was assessed. Results: In total, 66 077 patients were included. A decrease in prescribing of perioperative narcotics was noted. Risk factors for prolonged narcotic use included preoperative narcotic use, drug and substance use, lumbago, and depression. Preoperative narcotics were associated with increased emergency room visits, readmissions, CRPS, and infection. Prolonged postoperative narcotic use was linked to CRPS and revision surgery. Conclusions: Preoperative narcotic use is strongly associated with prolonged postoperative use. Both preoperative and prolonged postoperative prescriptions narcotic use correlated with increased risk of complications. Preoperative narcotic use is associated with a higher risk of postoperative CRPS.
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26
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Prentice HA, Chan PH, Namba RS, Inacio MC, Sedrakyan A, Paxton EW. Association of Type and Frequency of Postsurgery Care with Revision Surgery after Total Joint Replacement. Perm J 2020; 23:18.314. [PMID: 31926574 DOI: 10.7812/tpp/18.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Postmarket surveillance is limited in the ability to detect medical device problems. Electronic health records can provide real-time information that might help with device surveillance. Specifically, the frequency of postsurgery care might indicate early problems and determine high-risk patients requiring more active surveillance. OBJECTIVE To evaluate whether intensity of postsurgery care is associated with revision risk after total joint arthroplasty (TJA). DESIGN Using an integrated health care system's TJA registry, we identified primary TJA performed between April 2001 and July 2013 (22,953 knees and 9904 hips). Survival analyses evaluated the frequency of specific types of outpatient and inpatient utilization 0 to 90 and 91 to 180 days postoperatively and revision risk. MAIN OUTCOME MEASURES Revision surgery occurring at least 6 months after primary TJA. RESULTS Knee arthroplasty recipients with 3 or more outpatient orthopedic allied health/nurse visits within 90 days had a 2.2 times (95% confidence interval [CI] = 1.6-2.9) higher risk of revision within the first 2 years postoperatively and 10.1 times higher risk (95% CI = 7.6-13.3) after 2 years. Compared with hip arthroplasty recipients who had 0 to 3 visits, patients with 6 or more outpatient orthopedic office visits within 90 days had a 15.7 times (95% CI = 5.7-42.9) higher risk of revision. Similar results were observed for 91-day to 180-day visits. CONCLUSION Future studies are needed to determine if more specific data on reasons for the higher frequency of outpatient visits can refine these findings and elicit more specific recommendations for TJA devices.
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Affiliation(s)
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | | | - Maria Cs Inacio
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, NY
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27
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Prentice HA, Inacio MCS, Singh A, Namba RS, Paxton EW. Preoperative Risk Factors for Opioid Utilization After Total Hip Arthroplasty. J Bone Joint Surg Am 2019; 101:1670-1678. [PMID: 31567804 DOI: 10.2106/jbjs.18.01005] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid prescriptions following orthopaedic procedures may contribute to the opioid epidemic in the United States. Risk factors for greater and prolonged opioid utilization following total hip arthroplasty have yet to be fully elucidated. We sought to determine the prevalence of preoperative and postoperative opioid utilization in a cohort of patients who underwent total hip arthroplasty and to identify preoperative risk factors for prolonged utilization of opioids following total hip arthroplasty. METHODS A cohort study of patients who underwent primary elective total hip arthroplasty at Kaiser Permanente from January 2008 to December 2011 was conducted. The number of opioid prescriptions dispensed per 90-day period after total hip arthroplasty (up to 1 year) was the outcome of interest. The risk factors evaluated included preoperative analgesic medication use, patient demographic characteristics, comorbidities, and other history of chronic pain. Poisson regression models were used, and relative risks (RRs) and 95% confidence intervals (CIs) are presented. RESULTS Of the 12,560 patients who underwent total hip arthroplasty and were identified, 58.5% were female and 78.6% were white. The median age was 67 years (interquartile range, 59 to 75 years). Sixty-three percent of patients filled at least 1 opioid prescription in the 1 year prior to the total hip arthroplasty. Postoperative opioid use went from 88.6% in days 1 to 90 to 24% in the last quarter. An increasing number of preoperative opioid prescriptions was associated with a greater number of prescriptions over the entire postoperative period, with an RR of 1.10 (95% CI, 1.10 to 1.11) at days 271 to 360. Additional factors associated with greater utilization over the entire year included black race, chronic pulmonary disease, anxiety, substance abuse, and back pain. Factors associated with greater utilization in days 91 to 360 (beyond the early recovery phase) included female sex, higher body mass index, acquired immunodeficiency syndrome, peripheral vascular disease, and history of non-specific chronic pain. CONCLUSIONS We identified preoperative factors associated with greater and prolonged opioid utilization long after the early recovery period following total hip arthroplasty. Patients with these risk factors may benefit from targeted multidisciplinary interventions to mitigate the risk of prolonged opioid use. CLINICAL RELEVANCE Opioid prescriptions following orthopaedic procedures are one of the leading causes of chronic opioid use; strategies to reduce the risk of misuse and abuse are needed. At 1 year postoperatively, almost one-quarter of patients who underwent total hip arthroplasty used opioids in the last 90 days of the first postoperative year, which makes understanding risk factors associated with postoperative opioid utilization imperative.
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Affiliation(s)
- Heather A Prentice
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Maria C S Inacio
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California.,Registry of Older South Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Division of Health Sciences, Sansom Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Anshuman Singh
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, California
| | - Robert S Namba
- Department of Orthopaedics, Southern California Permanente Medical Group, Irvine, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
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28
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Lespasio MJ, Guarino AJ, Sodhi N, Mont MA. Pain Management Associated with Total Joint Arthroplasty: A Primer. Perm J 2019; 23:18-169. [PMID: 30939283 DOI: 10.7812/tpp/18-169] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This primer presents a synopsis of pain management strategies associated with total joint arthroplasty. Patients considering total joint arthroplasty often experience moderate to severe pain, which places them at risk of opioid abuse or addiction. Currently, the best practice strategies involve the development of individualized multimodal perioperative approaches to pain management. These practices include prescribing opioids at their lowest dose and for the shortest duration necessary to control symptoms, with close monitoring of common adverse effects. Implementing these practices is essential to battling the ongoing opioid crisis in the US.
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Affiliation(s)
| | - A J Guarino
- The Fullbright Specialist Program, Washington, DC
| | - Nipun Sodhi
- Lenox Hill Hospital, Northwell Health, New York, NY
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29
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Abstract
BACKGROUND The purpose of this study is to: (1) characterise risk factors for prolonged narcotic use following total hip arthroplasty (THA); (2) examine preoperative and prolonged postoperative narcotic use as independent risk factors for complications following THA. METHODS A national database identified primary THA patients from 2007-2015. Preoperative (POU) and prolonged postoperative narcotics users (PPU) were identified. A multivariable logistic regression analysis was utilised to identify any patient-related risk factors for prolonged use, and examined POU and PPU as risk factors for complications following THA. RESULTS 55,354 THA patients were included, 18,740 (33.8%) POU and 14,996 (27.1%) PPU. Preoperative narcotics use was the most significant factor associated with prolonged postoperative narcotic use. Preoperative and prolonged postoperative use were associated with significantly higher complications postoperatively. CONCLUSIONS Preoperative narcotic use is the most significant patient specific risk factor for prolonged postoperative narcotic use. POUs and PPUs are at a significantly higher risk of postoperative infection and revision surgery.
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Affiliation(s)
| | - Aaron A Casp
- University of Virginia Health System, Charlottesville, VA, USA
| | | | - Brian C Werner
- University of Virginia Health System, Charlottesville, VA, USA
| | - James A Browne
- University of Virginia Health System, Charlottesville, VA, USA
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30
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Thorlund JB, Turkiewicz A, Prieto-Alhambra D, Englund M. Opioid use in knee or hip osteoarthritis: a region-wide population-based cohort study. Osteoarthritis Cartilage 2019; 27:871-877. [PMID: 30682417 DOI: 10.1016/j.joca.2019.01.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 11/07/2018] [Accepted: 01/08/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To quantify opioid use in knee and hip osteoarthritis (OA) patients, and to estimate the proportion of opioids in the population attributable to OA patients. DESIGN Population-based cohort study. METHODS We included 751,579 residents in southern Sweden, aged ≥35 years in 2015. Doctor-diagnosed knee or hip OA between 1998 and 2015 was the exposure. Dispensed weak and strong opioids were identified between November 2013 and October 2015 from the Swedish Prescribed Drug Register (SPDR). We determined age- and sex-standardized 12-month period prevalence of opioid use from November 2014 until October 2015 and calculated prevalence ratios and incidence rate ratios adjusted for age, sex, and other socio-demographic variables. We estimated the population attributable fraction (PAF) of incident opioid use attributable to OA patients. RESULTS The 12-month prevalence of opioid use among OA patients was 23.7% [95% confidence intervals (CI) 23.3-24.2], which was two-fold higher compared to individuals without knee or hip OA: prevalence ratio: 2.1 [95% CI 2.1-2.1]. Similarly, OA patients were more likely to have an incident opioid dispensation, especially for strong opioids (incidence rate ratio: 2.6 [95% CI 2.5-2.7]). Population attributable tractions (PAF) of incident opioid use attributable to OA patients was 12%, 9% for weak and 17% for strong opioids. CONCLUSIONS Every fourth patient with knee or hip OA has opioids dispensed over a 1-year period, and 12% of incident opioid dispensations are attributable to OA and/or its related comorbidities. These results highlight that patients with knee and hip OA constitute a group of patients with an alarmingly high use of opioids.
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Affiliation(s)
- J B Thorlund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund, Sweden; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
| | - A Turkiewicz
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund, Sweden
| | - D Prieto-Alhambra
- GREMPAL (Grup de Recerca en Epidemiologia de Les Malalties Prevalents de L'Aparell Locomotor), Idiap Jordi Gol Primary Care Research Institute and CIBERFes, Universitat Autònoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain; Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine - Nuffield Department of Orthopaedics, Rheumatology, And Musculoskeletal Sciences, University of Oxford, UK
| | - M Englund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA, USA
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31
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Hinther A, Abdel-Rahman O, Cheung WY, Quan ML, Dort JC. Chronic Postoperative Opioid Use: A Systematic Review. World J Surg 2019; 43:2164-2174. [DOI: 10.1007/s00268-019-05016-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Indexed: 11/28/2022]
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Using Patient-Reported Outcomes to Predict Revision Arthroplasty Following Femoral Neck Fracture: Enhancing the Value of Clinical Registries through Data Linkage. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16081325. [PMID: 31013802 PMCID: PMC6517898 DOI: 10.3390/ijerph16081325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 11/24/2022]
Abstract
The aim of this study was to determine the association between patient-reported outcome measures (PROMs) six months following femoral neck fracture after a low fall and future arthroplasty, and the factors associated with this. Six-month post-fracture PROMs were collected from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) for patients aged >55 years who were admitted for a femoral neck fracture after a low fall between March 2007 and June 2015. These cases were linked with those registered by Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) up to October 2016. Multivariable analysis was performed using a Cox proportional hazards model to determine factors associated with future arthroplasty, including six-month PROMs. Of the 7077 hip fracture patients registered by VOTOR during the study period, 2325 met the inclusion criteria. Internal fixation being used for the initial hip fracture surgery, being younger and having no pre-injury disability were all independently associated with future revision or conversion to arthroplasty. Out of all PROMs, reporting pain and discomfort six months post-fracture was associated with a 9.5-fold increase in the risk of future arthroplasty (95% CI: 3.81, 23.67). The value of clinical registries can be enhanced via data linkage, in this case by using PROMs to predict arthroplasty following femoral neck fracture.
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Tran TDX, Wu CM, Dubey NK, Deng YH, Su CW, Pham TT, Thi Le PB, Sestili P, Deng WP. Time- and Kellgren⁻Lawrence Grade-Dependent Changes in Intra-Articularly Transplanted Stromal Vascular Fraction in Osteoarthritic Patients. Cells 2019; 8:E308. [PMID: 30987218 PMCID: PMC6523621 DOI: 10.3390/cells8040308] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 12/13/2022] Open
Abstract
Knee osteoarthritis (OA) is one of the most prevalent disorders in elderly population. Among various therapeutic alternatives, we employed stromal vascular fraction (SVF), a heterogeneous cell population, to regenerate damaged knee cartilage. OA patients were classified on the basis of age, gender, body mass index (BMI), and x-ray-derived Kellgren-Lawrence (KL) grade. They were treated with SVF and followed-up for 24 months. Visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index were used to determine treatment efficacy. Cartilage healing was assessed using the MRI-based Outerbridge score (OS) and evaluation of bone marrow edema (BME) lesions, while a placebo group was used as a control. Time- and KL-dependent changes were also monitored. We observed a decreasing trend in VAS score and WOMAC index in the SVF-treated group up to 24 months, as compared with the placebo group. Besides, a significant increase and decrease in Lysholm and OS, respectively, were observed in the treatment group. Compared with the values before treatment, the greatly reduced WOMAC scores of KL3 than KL2 groups at 24 months, indicate more improvement in the KL3 group. Highly decreased BME in the treated group was also noted. In conclusion, the SVF therapy is effective in the recovery of OA patients of KL3 grade in 24 months.
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Affiliation(s)
- Tung Dang Xuan Tran
- School of Dentistry, Taipei Medical University, Taipei 11031, Taiwan.
- Van Hanh Stem Cells Unit, Van Hanh Hospital, Ho Chi Minh City 700000, Vietnam.
| | - Chi-Ming Wu
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan.
| | - Navneet Kumar Dubey
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan.
- Stem Cell Research Center, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan.
| | - Yue-Hua Deng
- Department of Life Science, Fu Jen Catholic University, New Taipei City 242, Taiwan.
| | - Chun-Wei Su
- Stem Cell Research Center, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan.
| | - Tu Thanh Pham
- Van Hanh Stem Cells Unit, Van Hanh Hospital, Ho Chi Minh City 700000, Vietnam.
| | - Phuong Bich Thi Le
- Department of Pulmonary Medicine, Vietnam Military Medical Academy, Ha Noi 12108, Vietnam.
| | - Piero Sestili
- Dipartimento di Scienze Biomolecolari, Università degli Studi di Urbino Carlo Bo Via "I Maggetti" 26, 61029 Urbino, Italy.
| | - Win-Ping Deng
- School of Dentistry, Taipei Medical University, Taipei 11031, Taiwan.
- Stem Cell Research Center, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan.
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Saigal AN, Jones HM. Interdisciplinary Mitigation of Opioid Misuse in Musculoskeletal Patients. HSS J 2019; 15:72-75. [PMID: 30863236 PMCID: PMC6384213 DOI: 10.1007/s11420-018-09656-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The opioid prescribing patterns of orthopedic surgeons have been shown to play a role in exacerbating rates of opioid misuse among post-surgical patients. Demonstrable success has been appreciated by combining policy-level approaches and clinical education-based strategies to inform patients of alternative modalities of post-operative analgesia. QUESTIONS/PURPOSES The purpose of this review was to address two questions: What are the most substantiated measures orthopedic surgeons can take to limit opioid misuse or addiction among their patients? What advantages are gained in orthopedic surgeons' collaborating with other healthcare professionals with influence over patients' post-operative opioid exposure? METHODS We searched two databases for articles on multidisciplinary policy-based solutions to mitigating the opioid overdose crisis among musculoskeletal patients. Articles produced from the search were searched for further evidence supporting the use of standardized clinical and administrative protocols in mitigating opioid misuse within this patient population. Successful approaches to mitigating misuse of opioids in this demographic were synthesized from recurring themes in the studies. RESULTS Multiple articles support orthopedic surgeons being aware of the risk factors for chronic opioid use among their patients, as well as multidisciplinary strategies involving orthopedic surgeons and other healthcare/governmental professionals to address the burden of the opioid crisis on surgical patients. CONCLUSIONS Addressing the misuse of opioids among orthopedic patients requires appropriate prescribing practices and long-term support of patients. Collaboration between surgeons and policymaking entities is recognized as an effective population-wide approach to preventing opioid dependence, misuse, and addiction.
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Affiliation(s)
- Ammar N. Saigal
- Department of Surgery, Weill Cornell Medicine, 1320 York Avenue, Apt. # 28A, New York, NY 10021 USA
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY USA
| | - Henderson M. Jones
- Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX USA
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Agrawal Y, Smith RM, Garbuz DS, Masri BA. Opioids in Arthroplasty: Mind the Gap Between North America and the Rest of the World. J Bone Joint Surg Am 2018; 100:2162-2171. [PMID: 30562297 DOI: 10.2106/jbjs.17.01422] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Yuvraj Agrawal
- Department of Orthopaedics, Northern General Hospital, Sheffield, United Kingdom.,Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - R Malcolm Smith
- Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts
| | - Donald S Garbuz
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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36
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Freeman R, Edwards R, Baron R, Bruehl S, Cruccu G, Dworkin RH, Haroutounian S. AAPT Diagnostic Criteria for Peripheral Neuropathic Pain: Focal and Segmental Disorders. THE JOURNAL OF PAIN 2018; 20:369-393. [PMID: 30527971 DOI: 10.1016/j.jpain.2018.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 09/27/2018] [Accepted: 10/02/2018] [Indexed: 12/19/2022]
Abstract
Peripheral neuropathic pain is among the most prevalent types of neuropathic pain. No comprehensive peripheral neuropathic pain classification system that incorporates contemporary clinical, diagnostic, biological, and psychological information exists. To address this need, this article covers the taxonomy for 4 focal or segmental peripheral neuropathic pain disorders, as part of the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership and the American Pain Society (APS) collaborative to develop a standardized, evidence-based taxonomy initiative: the ACTTION-APS Pain Taxonomy (AAPT). The disorders-postherpetic neuralgia, persistent posttraumatic neuropathic pain, complex regional pain disorder, and trigeminal neuralgia-were selected because of their clinical and clinical research relevance. The multidimensional features of the taxonomy are suitable for clinical trials and can also facilitate hypothesis-driven case-control and cohort epidemiologic studies. PERSPECTIVE: The AAPT peripheral neuropathic pain taxonomy subdivides the peripheral neuropathic pain disorders into those that are generalized and symmetric and those that are focal or segmental and asymmetric. In this article, we cover the focal and segmental disorders: postherpetic neuralgia, persistent posttraumatic neuropathic pain, complex regional pain disorder, and trigeminal neuralgia. The taxonomy is evidence-based and multidimensional, with the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.
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Affiliation(s)
- Roy Freeman
- Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Robert Edwards
- Department of Anesthesiology, Brigham & Women's Hospital, Harvard University School of Medicine, Boston, MA
| | - Ralf Baron
- University of Kiel, Division of Neurological Pain Research and Therapy, Department of Neurology, Kiel, Germany
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Giorgio Cruccu
- Department Human Neuroscience, Sapienza University, Rome, Italy
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Simon Haroutounian
- Department of Anesthesiology and Washington University Pain Center, Washington University School of Medicine, St Louis, MO
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Namba RS, Paxton EW, Inacio MC. Opioid Prescribers to Total Joint Arthroplasty Patients Before and After Surgery: The Majority Are Not Orthopedists. J Arthroplasty 2018; 33:3118-3124.e3. [PMID: 29934272 DOI: 10.1016/j.arth.2018.05.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/16/2018] [Accepted: 05/22/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Improved narcotic pain management after total joint arthroplasty (TJA) is necessary to help battle the opioid epidemic. The goal of this study was to determine the sources of prescriptions prescribed to TJA patients. METHODS An evaluation of opioid use in patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) was performed between 2008 and 2012. Using a Total Joint Replacement Registry and pharmacy data, opioids dispensed to TJA patients were identified. The main outcome of interest was who prescribed opioids to patients in the year before and after surgery. RESULTS Primary care (pre-TKA 31% TKA, post-TKA 38%, pre-THA 34%, post-THA 40%) and internal medicine (27% pre-TKA, post-TKA 37%, pre-THA 32%, post-THA 40%) were the highest prescribers in the year before, and after, TJA. For TKA patients, orthopedists prescribed 9% of the opioids in the year before surgery, 47% in days 1-90 after surgery, and 14% in days 271-360. Similarly, in THA patients, orthopedists prescribed 14% of the opioids in the year before surgery, 40% in days 1-90 after surgery, and 14% in days 271-360. CONCLUSION Patients receive opioid prescriptions from multiple physician types before, and after, TJA. The majority of preoperative, and late postoperative, narcotics were not provided by their surgeons. Orthopedic surgeons may not even know that their TJA patients continue to receive opioids. Coordination of opioid care with health-care providers and greater communication with patients on narcotic use expectations should be promoted.
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Affiliation(s)
- Robert S Namba
- Southern California Permanente Medical Group, Irvine, California
| | - Elizabeth W Paxton
- Kaiser Permanente, Surgical Outcomes and Analysis, San Diego, California
| | - Maria C Inacio
- Kaiser Permanente, Surgical Outcomes and Analysis, San Diego, California; South Australian Health and Medical Research Institute, Adelaide, Australia
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Patients With Hip or Knee Arthritis Underreport Narcotic Usage. J Arthroplasty 2018; 33:3113-3117. [PMID: 29909957 DOI: 10.1016/j.arth.2018.05.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/10/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients taking narcotics chronically are more likely to have worse outcomes after total joint arthroplasty. These negative outcomes may be avoided when modifiable risk factors such as narcotic use are identified and improved before elective joint replacement. An accurate assessment of narcotic use is needed to identify patients before surgery. This study examines the amount of reported narcotic use in patients with hip or knee osteoarthritis and compares this with the narcotic prescriptions recorded in our state's drug prescription monitoring database. METHODS All new patients seen during a 1-year period by our adult reconstruction practice were identified. Patients' electronic health records were reviewed to determine whether narcotic use was reported. A subsequent search was performed using the Arkansas Prescription Drug Monitoring Program to determine if the patient had been previously prescribed a narcotic. RESULTS A total of 502 patients were included in the study. One hundred seventy patients (34%) were prescribed a narcotic within 3 months of the clinic visit according to the Arkansas Prescription Drug Monitoring Program, but only 111 (22%) reported narcotic use in their electronic health record (P < .0001). Moreover, only 92 patients (54% of 170) prescribed a narcotic within 3 months reported it. Narcotic recipients were more likely to be under the age of 65 years (P = .0081), smokers (P < .0001), and current benzodiazepine users (P < .0001). CONCLUSION This study demonstrates that patients significantly underreport their narcotic use to their physician. The availability of a state prescription drug monitoring program allows physicians to check the frequency of filled narcotic prescriptions by their patients.
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Murimi IB, Ghambaryan A, Decker R, Lu X, Segal R, Loyo-Berrios N, Marinac-Dabic D, Hartzema AG. Association Between Recombinant Human Bone Morphogenetic Proteins and Postoperative Opioid Use in Lumbar Fusion Procedure Patients: A Propensity Score-Matched Analysis. World Neurosurg 2018; 120:e42-e52. [PMID: 30170146 DOI: 10.1016/j.wneu.2018.07.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Little is known about the effectiveness of recombinant human bone morphogenetic proteins (rhBMPs) in reducing the demand for opioids after surgery. We investigated the association between rhBMP use and the likelihood of achieving opioid independence and changes in opioid demand in the first postoperative year. METHODS Using the Multi-Payer Claims Database from 2007 to 2010, patients aged >20 years who had undergone a degenerative disc disease-indicated lumbar fusion procedure and had had ≥1 opioid prescription in the 3 months before surgery were identified. Propensity score matching (1:1) of rhBMP-exposed and rhBMP-unexposed patients was used to mitigate confounding. The outcomes of interest were opioid independence and decreases in opioid doses in morphine equivalent units, assessed at 3-6 and 9-12 months after the procedure. Logistic regression and analysis of covariance models were used. RESULTS The data from 318 patients were analyzed. Most patients were women (61%) and aged <65 years (68%). Few had achieved opioid independence at 3-6 (n = 71; 22.3%) or 9-12 (n = 115; 36.2%) months postoperatively. During the 3-6-month window, the rhBMP group reduced their opioid use rates (estimated mean difference. -28.4 vs. -19.5; P = 0.69) and achieved opioid independence (21.4% vs. 23.3%; odds ratio, 0.92; 95% confidence interval, 0.54-1.56; P = 0.74) at rates that were statistically comparable to their matched comparators. Similar patterns were observed during the 9-12-month window. CONCLUSION We found no evidence to suggest that rhBMP use during spinal fusion procedures is associated with either the discontinuation or decrease of opioid analgesic therapy. The continued opioid use after surgery warrants further clinical and research attention.
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Affiliation(s)
- Irene B Murimi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Anna Ghambaryan
- Division of Epidemiology, Office of Surveillance, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Decker
- Department of Orthopedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Xiaomin Lu
- Department of Biostatistics, College of Public Health & Health Professions, University of Florida, Gainesville, Florida, USA
| | - Richard Segal
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Nilsa Loyo-Berrios
- Division of Epidemiology, Office of Surveillance, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Danica Marinac-Dabic
- Division of Epidemiology, Office of Surveillance, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Abraham G Hartzema
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA; Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
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Cryar KA, Hereford T, Edwards PK, Siegel E, Barnes CL, Mears SC. Preoperative Smoking and Narcotic, Benzodiazepine, and Tramadol Use are Risk Factors for Narcotic Use After Hip and Knee Arthroplasty. J Arthroplasty 2018; 33:2774-2779. [PMID: 29705679 DOI: 10.1016/j.arth.2018.03.066] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/21/2018] [Accepted: 03/30/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of narcotics has been found to be a modifiable risk factor for success of arthroplasty. We sought to determine the risk factors leading to increased narcotic use after total hip arthroplasty and total knee arthroplasty. METHODS A retrospective chart review was performed on new patients presenting to an orthopedic reconstructive-service clinic. New patients aged 18 years or older with osteoarthritis of the hip or knee who presented over a 1-year period and underwent total knee arthroplasty or total hip arthroplasty were included. The Arkansas prescription monitoring program was then used to determine recent narcotic and benzodiazepine prescriptions filled within 3 months of surgery, and this was converted into morphine milligram equivalents (MME). RESULTS One hundred seventy-nine patients met the inclusion criteria. When compared with patients who did not take any preoperative opioids, narcotic- and tramadol-only users filled an average of 86% and 38% more MME, respectively. Benzodiazepine users required an average of 81% more MME postoperative than nonusers, and smokers required an average of 90% more MME postoperative than nonsmokers. Subjects with body mass index >40 kg/m2 had 82% higher average postoperative MME than subjects with body mass index <25 kg/m2. Age and sex had no significant correlation with postoperative narcotic use. CONCLUSION This study suggests that a patient's preoperative narcotic, tramadol, benzodiazepine, and tobacco use are correlated to the amount of postoperative narcotic prescriptions filled in the 3 months following surgery. Predisposition to substance abuse may be a characteristic which leads to increased postoperative narcotic use.
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Affiliation(s)
- Kipp A Cryar
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Timothy Hereford
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Paul K Edwards
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eric Siegel
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Bedard NA, DeMik DE, Dowdle SB, Owens JM, Liu SS, Callaghan JJ. Does Preoperative Opioid Use Increase the Risk of Early Revision Total Hip Arthroplasty? J Arthroplasty 2018; 33:S154-S156. [PMID: 29452972 DOI: 10.1016/j.arth.2018.01.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the impact of preoperative opioid use on the risk of subsequent revison after primary total hip arthroplasty (THA). METHODS The Humana database was queried for unilateral THA between 2007-2015. Patients were tracked for the occurrence of an ipsilateral revision THA for 2 years. Factors analyzed included preoperative opioid use (defined as a history of opioid prescription filled within 3 months preceding primary THA), age, sex, diabetes, anxiety/depression, chronic kidney disease, and obesity (body mass index > 30 kg/m2). Multivariate logistic regression analysis was used to determine odds ratios. RESULTS A total of 17,695 primary THA patients were analyzed and 0.88% (n = 155) underwent revision THA within 2 years. Preoperative opioid use occurred in 36.7% of all. Females comprised 58.7% of the total cohort and 80% were >50 years. Preoperative opioid users were significantly more likely to undergo early THA revision (1.2% vs 0.7%, P < .001). Other patient factors that significantly increased the risk of early THA revision included obesity (1.3% vs 0.8%, P = .03) and a preoperative diagnosis of anxiety/depression (1.9% vs 0.8%, P = .006). CONCLUSION Opioid use within 3 months preceding THA independently predicts an increased risk of early revision. Additionally, independent predictors of early revision include obesity and a diagnosis of anxiety/depression. Factors such as these will need to be considered in risk adjustment models when assessing quality of care or implementing bundled payment initiatives. Further research is needed to evaluate whether discontinuing opioids before surgery mitigates this risk.
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Affiliation(s)
| | - David E DeMik
- Department of Orthopaedics, University of Iowa, Iowa City, IA
| | - S Blake Dowdle
- Department of Orthopaedics, University of Iowa, Iowa City, IA
| | - Jessell M Owens
- Department of Orthopaedics, University of Iowa, Iowa City, IA
| | - Steve S Liu
- Department of Orthopaedics, University of Iowa, Iowa City, IA
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Namba RS, Inacio MCS, Pratt NL, Graves SE, Roughead EE, Paxton EW. Persistent Opioid Use Following Total Knee Arthroplasty: A Signal for Close Surveillance. J Arthroplasty 2018; 33:331-336. [PMID: 28974377 DOI: 10.1016/j.arth.2017.09.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/23/2017] [Accepted: 09/05/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prolonged opioid use following total knee arthroplasty (TKA) has not been extensively studied. METHODS A cohort study of primary TKA for osteoarthritis using an integrated healthcare system and Total Joint Replacement Registry (January 2008-December 2011) was conducted. Opioid use during the first year after TKA was the exposure of interest and cumulative daily oral morphine equivalent (OME) amounts were calculated. Total postsurgical OME per 90-day exposure periods were categorized into quartiles. The end point was aseptic revision surgery. Survival analyses were conducted and hazard ratios (HRs) were adjusted for age, gender, prior analgesic use, opioid-related comorbidities, and chronic pain diagnoses. RESULTS A total of 24,105 patients were studied. After the initial 90-day postoperative period, 41.5% (N = 9914) continued to use opioids. Also, 155 (0.6%) revisions occurred within 1 year and 377 (1.6%) within 5 years. Compared to patients not taking any opioids, patients using medium-low to high OME after the initial 90-day period had a higher adjusted risk of 1-year revision, ranging from HR = 2.4 (95% confidence interval, 1.3-4.5) to HR = 33 (95% confidence interval, 10-110) depending on the OME and time period. CONCLUSION Patients who require opioids beyond 90 days after TKA warrant close follow-up.
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Affiliation(s)
- Robert S Namba
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Irvine, California
| | - Maria C S Inacio
- Medicine and Devices Surveillance Centre of Research Excellence, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia
| | - Nicole L Pratt
- Medicine and Devices Surveillance Centre of Research Excellence, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia
| | - Stephen E Graves
- Australian Orthopaedic Association National Total Joint Replacement Registry, Adelaide, South Australia
| | - Elizabeth E Roughead
- Medicine and Devices Surveillance Centre of Research Excellence, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
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Stark N, Kerr S, Stevens J. Prevalence and Predictors of Persistent Post-Surgical Opioid Use: A Prospective Observational Cohort Study. Anaesth Intensive Care 2017; 45:700-706. [DOI: 10.1177/0310057x1704500609] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Post-surgical opioid prescribing intended for the short-term management of acute pain may lead to long-term opioid use. This study was undertaken to determine the prevalence of persistent post-surgical opioid use and patient-related factors associated with post-surgical opioid use. One thousand and thirteen opioid-naïve patients awaiting elective surgery in a tertiary private hospital in Sydney were enrolled. Preoperatively, patients completed a questionnaire comprising potential predictors of persistent post-surgical opioid use. Patients underwent surgery with routine perioperative care, and were followed up at 90 to 120 days after surgery to determine opioid use. Factors associated with opioid use were assessed with logistic regression. We had an overall response rate of 95.8% (n=970) of patients, of whom 10.5% (n=102) continued to use opioids at >90 days after surgery. On surgical subtype analysis, the prevalence of persistent opioid use was 23.6% after spinal surgery, and 13.7% after orthopaedic surgery. Four factors were independently associated with persistent post-surgical opioid use in a multivariate model: having orthopaedic (odds ratio [OR] 4.6, 95% confidence interval [CI] 2.0 to 10.8, P <0.001) or spinal surgery (OR 4.0, 95% CI 1.7 to 9.2, P <0.001), anxiety (OR 2.1, 95% CI 1.1 to 4.1, P=0.03), attending pre-admission clinic (OR 3.7, 95% CI 1.6 to 8.6, P=0.002), and higher self-reported pain score at >90 days after surgery (P <0.001). More than 10% of opioid-naïve patients undergoing elective surgery experience persistent post-surgical opioid use. Identification of factors associated with persistent post-surgical opioid use may allow development of a risk stratification tool to predict those at highest risk.
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Affiliation(s)
- N. Stark
- School of Medicine, University of Notre Dame Sydney, Sydney, New South Wales
| | - S. Kerr
- The Kirby Institute, University of New South Wales, Sydney, New South Wales
| | - J. Stevens
- Anaesthetist and Pain Medicine Specialist, Department of Anaesthetics, St Vincent's Private Hospital Sydney, Sydney, New South Wales
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Kim SC, Choudhry N, Franklin JM, Bykov K, Eikermann M, Lii J, Fischer MA, Bateman BT. Patterns and predictors of persistent opioid use following hip or knee arthroplasty. Osteoarthritis Cartilage 2017; 25:1399-1406. [PMID: 28433815 PMCID: PMC5565694 DOI: 10.1016/j.joca.2017.04.002] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 04/06/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The relationship between arthroplasty and long-term opioid use in patients with knee or hip osteoarthritis is not well studied. We examined the prevalence, patterns and predictors of persistent opioid use after hip or knee arthroplasty. METHOD Using claims data (2004-2013) from a US commercial health plan, we identified adults who underwent hip or knee arthroplasty and filled ≥1 opioid prescription within 30 days after the surgery. We defined persistent opioid users as patients who filled ≥1 opioid prescription every month during the 1-year postoperative period based on group-based trajectory models. Multivariable logistic regression was used to determine preoperative predictors of persistent opioid use after surgery. RESULTS We identified 57,545 patients who underwent hip or knee arthroplasty. The mean ± SD age was 61.5 ± 7.8 years and 87.1% had any opioid use preoperatively. Overall, 7.6% persistently used opioids after the surgery. Among patients who used opioids in 80% of the time for ≥4 months preoperatively (n = 3023), 72.1% became persistent users. In multivariable analysis, knee arthroplasty vs hip, a longer hospitalization stay, discharge to a rehabilitation facility, preoperative opioid use (e.g., a longer duration and greater dosage and frequency), a higher comorbidity score, back pain, rheumatoid arthritis, fibromyalgia, migraine and smoking, and benzodiazepine use at baseline were strong predictors for persistent opioid use (C-statistic = 0.917). CONCLUSION Over 7% of patients persistently used opioids in the year after hip or knee arthroplasty. Given the adverse health effects of persistent opioid use, strategies need to be developed to prevent persistent opioid use after this common surgery.
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Affiliation(s)
- S C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - N Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - K Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - J Lii
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - B T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Escobar Ivirico JL, Bhattacharjee M, Kuyinu E, Nair LS, Laurencin CT. Regenerative Engineering for Knee Osteoarthritis Treatment: Biomaterials and Cell-Based Technologies. ENGINEERING (BEIJING, CHINA) 2017; 3:16-27. [PMID: 35392109 PMCID: PMC8986132 DOI: 10.1016/j.eng.2017.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Knee osteoarthritis (OA) is the most common form of arthritis worldwide. The incidence of this disease is rising and its treatment poses an economic burden. Two early targets of knee OA treatment include the predominant symptom of pain, and cartilage damage in the knee joint. Current treatments have been beneficial in treating the disease but none is as effective as total knee arthroplasty (TKA). However, while TKA is an end-stage solution of the disease, it is an invasive and expensive procedure. Therefore, innovative regenerative engineering strategies should be established as these could defer or annul the need for a TKA. Several biomaterial and cell-based therapies are currently in development and have shown early promise in both preclinical and clinical studies. The use of advanced biomaterials and stem cells independently or in conjunction to treat knee OA could potentially reduce pain and regenerate focal articular cartilage damage. In this review, we discuss the pathogenesis of pain and cartilage damage in knee OA and explore novel treatment options currently being studied, along with some of their limitations.
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Affiliation(s)
- Jorge L. Escobar Ivirico
- Institute for Regenerative Engineering, University of Connecticut Health Center, Farmington, CT 06030, USA
- Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Maumita Bhattacharjee
- Institute for Regenerative Engineering, University of Connecticut Health Center, Farmington, CT 06030, USA
- Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Emmanuel Kuyinu
- Institute for Regenerative Engineering, University of Connecticut Health Center, Farmington, CT 06030, USA
- Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Lakshmi S. Nair
- Institute for Regenerative Engineering, University of Connecticut Health Center, Farmington, CT 06030, USA
- Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
- Department of Biomedical Engineering, School of Engineering, University of Connecticut, Storrs, CT 06269, USA
- Department of Materials Science and Engineering, School of Engineering, University of Connecticut, Storrs, CT 06269, USA
- Institute of Materials Science, University of Connecticut, Storrs, CT 06269, USA
| | - Cato T. Laurencin
- Institute for Regenerative Engineering, University of Connecticut Health Center, Farmington, CT 06030, USA
- Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
- Department of Biomedical Engineering, School of Engineering, University of Connecticut, Storrs, CT 06269, USA
- Department of Materials Science and Engineering, School of Engineering, University of Connecticut, Storrs, CT 06269, USA
- Institute of Materials Science, University of Connecticut, Storrs, CT 06269, USA
- Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut Health Center, Farmington, CT 06030, USA
- Department of Chemical and Biomolecular Engineering, School of Engineering, University of Connecticut, Storrs, CT 06269, USA
- Corresponding author.
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