1
|
Bahoravitch T, Roberts M, Zhao A, Stake S, Ernst B, Thakkar SC. Trends From 2010 to 2019 in Opioid and Nonopioid Pain Management After Total Knee Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202406000-00006. [PMID: 38866713 PMCID: PMC11175854 DOI: 10.5435/jaaosglobal-d-23-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 03/04/2024] [Accepted: 03/11/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION As the opioid epidemic enters its third decade, we reflect on how it has affected clinical practice within the orthopaedic community. Recent studies show prolonged opioid use after total knee arthroplasty (TKA) is associated with worse overall health outcomes. This study aims to elucidate trends in pain management after TKA over the past decade. METHODS A retrospective analysis was performed using the PearlDiver database from 2010 to 2019. Patients who underwent primary TKA without a history of mental illness, complex pain syndromes, or opioids used 6 months before surgery were selected. Postoperative prescription filling rates of opioid and nonopioid at 30, 90 days, and 1 year from surgery were analyzed. Linear regression analysis and compound annual growth rates (CAGRs) were analyzed from 2010 to 2019, a P value <0.05 being considered significant. RESULTS Between 2010 and 2019, 579,269 patients underwent primary TKA. At 30 days, filling of prescriptions for opioids (CAGR = 3.54%) and nonopioids (CAGR = 15.50%) markedly increased from 2010 to 2019. At 90 days, opioids decreased (CAGR = -4.42%). At 1 year, opioid (CAGR = -10.92%) and nonopioid (CAGR = -2.12%) prescriptions markedly decreased from 2010 to 2019. DISCUSSION This study highlights patterns of decreased opioid prescription rates at 90 days and 1 year postoperatively from 2010 to 2019. Decreasing opioid rates may indicate effectiveness in targeted public health campaigns to curb opioid overuse.
Collapse
Affiliation(s)
- Tyler Bahoravitch
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Max Roberts
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Amy Zhao
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Seth Stake
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Brady Ernst
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Savyasachi C. Thakkar
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| |
Collapse
|
2
|
Nnake CO, El-Othmani MM, Cooper HJ, Shah RP, Geller JA, Neuwirth AL. Genicular nerve radiofrequency ablation: a systematic review of application for perioperative pain control in total knee arthroplasty and as treatment for chronic pain in well-appearing total knee arthroplasty. Knee Surg Relat Res 2024; 36:18. [PMID: 38764084 PMCID: PMC11103950 DOI: 10.1186/s43019-024-00222-9] [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: 10/18/2023] [Accepted: 03/26/2024] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a successful treatment for end-stage osteoarthritis, yet some patients still experience postoperative pain. Genicular nerve radiofrequency ablation (GNRFA) has become a potential modality to address pain in TKA. This systematic review aims to critically analyze the applicability of GNRFA in perioperative pain control prior to TKA, as well as a treatment modality for chronic painful well-appearing TKA. METHODS PubMed, Medline, EMBASE, Google Scholar, Scopus, and COCHRANE databases, as well as the ClinicalTrials.gov register, were reviewed. The search included randomized controlled trials and cohort studies. The sample population focused on two cohorts; those who underwent TKA and utilized intentional GNRFA as a perioperative pain control modality, and those utilizing the treatment modality for chronic pain in well-appearing TKA. GNRFA was the intervention studied, and postoperative outcomes were compared with the control group, which consisted of those not receiving GNRFA. RESULT Eight total publications were identified as relevant to this search. Among the pre-TKA studies, there was variability in results; these inconsistencies were attributed to a lack of standardization, especially with regard to type, timing, and targeted nerves with ablation. Likewise, while the results were improved among the population with chronic painful TKA receiving GNRFA, these inconsistencies still existed. CONCLUSIONS Current evidence suggests GNRFA as a possible pre-TKA intervention to potentially minimize opioid consumption, patient-reported pain, length of stay, and increased range of motion and activity. However, the short-lived duration in the setting of chronically painful well-appearing TKA represents a major barrier that warrants further investigation. Limitations include small sample size, heterogeneity, lack of standardization of techniques among studies, and lack of direct comparison and meta-analysis. Further research should focus on the standardization of technique as well as analyzing various patient and health-system-related factors that correlate with sustained positive outcomes.
Collapse
Affiliation(s)
- Chidebelum O Nnake
- Division of Hip and Knee Reconstruction, Columba University Medical Center, New York-Presbyterian Hospital, 622 West 168t Street, PH 11- Center, New York, NY, 10032, USA
| | - Mouhanad M El-Othmani
- Division of Hip and Knee Reconstruction, Columba University Medical Center, New York-Presbyterian Hospital, 622 West 168t Street, PH 11- Center, New York, NY, 10032, USA
| | - H John Cooper
- Division of Hip and Knee Reconstruction, Columba University Medical Center, New York-Presbyterian Hospital, 622 West 168t Street, PH 11- Center, New York, NY, 10032, USA
| | - Roshan P Shah
- Division of Hip and Knee Reconstruction, Columba University Medical Center, New York-Presbyterian Hospital, 622 West 168t Street, PH 11- Center, New York, NY, 10032, USA
| | - Jeffrey A Geller
- Division of Hip and Knee Reconstruction, Columba University Medical Center, New York-Presbyterian Hospital, 622 West 168t Street, PH 11- Center, New York, NY, 10032, USA
| | - Alexander L Neuwirth
- Division of Hip and Knee Reconstruction, Columba University Medical Center, New York-Presbyterian Hospital, 622 West 168t Street, PH 11- Center, New York, NY, 10032, USA.
| |
Collapse
|
3
|
Singh K, Tsang S, Zvara J, Roach J, Walters S, McNeil J, Jossart S, Abdel-Malek A, Yount K, Mazzeffi M. Intraoperative Methadone Use Is Associated With Reduced Postoperative Pain and More Rapid Opioid Weaning After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00322-7. [PMID: 38876810 DOI: 10.1053/j.jvca.2024.05.012] [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: 03/10/2024] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE To explore the association between intraoperative methadone use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG) surgery. DESIGN Retrospective cohort study. SETTING Single academic medical center. PARTICIPANTS Patients undergoing isolated CABG over a 5-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic data, comorbidities, and intraoperative anesthetic medications were recorded. Primary study outcomes were average and maximum pain scores and morphine milligram equivalent consumption on the first 2 postoperative days (PODs). Linear mixed-effects regression models were used to examine the effect of intraoperative methadone use on study outcomes. Among 1,338 patients, 78.6% received intraoperative methadone (0.2 mg/kg). Patients who did not receive methadone had higher average (estimated [Est], 0.48; 95% confidence interval [CI], 0.22-0.73; p < 0.001) and maximum postoperative (Est, 0.49; 95% CI, 0.23-0.75; p < 0.001) pain scores over PODs 0 to 2. For postoperative opioid consumption, there was a significant intraoperative methadone use-time interaction effect on postoperative opioid use (odds ratio [OR], 2.21; 95% CI, 1.74-2.80; p < 0.001). Across PODs 0 to 2, patients who received intraoperative methadone had a faster decline in postoperative opioid use than those who did not receive intraoperative methadone. Patients who did not receive intraoperative methadone were extubated slightly faster (OR, 0.82; 95% CI, 0.72-0.93; p < 0.01). CONCLUSIONS Our data suggest that the use of intraoperative methadone is safe, reduces postoperative pain, and expedites weaning from postoperative opioids after CABG surgery.
Collapse
Affiliation(s)
- Karen Singh
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Siny Tsang
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Jessica Zvara
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Joshua Roach
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Susan Walters
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - John McNeil
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Scott Jossart
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Amir Abdel-Malek
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Kenan Yount
- Department of Cardiothoracic Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA.
| |
Collapse
|
4
|
Yoo JD, Huh MH, Lee SH, D'Lima DD, Shin YS. A Network Meta-Analysis of Randomized Controlled Trials Assessing Intraoperative Anesthetic Therapies for Analgesic Efficacy and Morphine Consumption Following Total Knee Arthroplasty. J Arthroplasty 2024; 39:1361-1373. [PMID: 37952743 DOI: 10.1016/j.arth.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND The purpose of this study was to compare intraoperative anesthetic therapies for total knee arthroplasty (TKA) regarding postoperative analgesic efficacy and morphine consumption by conducting a systematic literature search. METHODS Randomized controlled trials of TKA using various anesthetic therapies were identified from various databases from conception through December 31, 2021. A network meta-analysis of relevant literature was performed to investigate which treatment showed better outcomes. In total, 40 trials were included in this study. RESULTS Surface under the cumulative ranking curve showed local infiltration anesthesia (LIA) with saphenous nerve block (SNB) to produce the best pain relief on postoperative days (PODs) 1 and 2 and the best reduction of morphine consumption on PODs 1 and 3. However, femoral nerve block showed the largest effect on pain relief on POD 3, and liposomal bupivacaine showed the largest effect on reduction of morphine consumption on POD 2. CONCLUSIONS According to this network meta-analysis, surface under the cumulative ranking curve percentage showed that LIA with SNB provided the best analgesic effect after TKA. Furthermore, patients receiving LIA with SNB had the lowest consumption of morphine. Although femoral nerve block resulted in better pain relief on POD 3, LIA with SNB could be selected first when trying to reduce morphine consumption or increase early ambulation.
Collapse
Affiliation(s)
- Jae-Doo Yoo
- Department of Orthopaedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Min-Hwan Huh
- Department of Medicine, The Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Seung-Hyun Lee
- Department of Orthopaedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Darryl D D'Lima
- Shiley Center for Orthopaedic Research and Education, Scripps Health, La Jolla, California
| | - Young-Soo Shin
- Department of Orthopaedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| |
Collapse
|
5
|
Su TF, Hamilton JD, Guo Y, Potas JR, Shivdasani MN, Moalem-Taylor G, Fridman GY, Aplin FP. Peripheral direct current reduces naturally evoked nociceptive activity at the spinal cord in rodent models of pain. J Neural Eng 2024; 21:026044. [PMID: 38579742 DOI: 10.1088/1741-2552/ad3b6c] [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: 08/25/2023] [Accepted: 04/05/2024] [Indexed: 04/07/2024]
Abstract
Objective.Electrical neuromodulation is an established non-pharmacological treatment for chronic pain. However, existing devices using pulsatile stimulation typically inhibit pain pathways indirectly and are not suitable for all types of chronic pain. Direct current (DC) stimulation is a recently developed technology which affects small-diameter fibres more strongly than pulsatile stimulation. Since nociceptors are predominantly small-diameter Aδand C fibres, we investigated if this property could be applied to preferentially reduce nociceptive signalling.Approach.We applied a DC waveform to the sciatic nerve in rats of both sexes and recorded multi-unit spinal activity evoked at the hindpaw using various natural stimuli corresponding to different sensory modalities rather than broad-spectrum electrical stimulus. To determine if DC neuromodulation is effective across different types of chronic pain, tests were performed in models of neuropathic and inflammatory pain.Main results.We found that in both pain models tested, DC application reduced responses evoked by noxious stimuli, as well as tactile-evoked responses which we suggest may be involved in allodynia. Different spinal activity of different modalities were reduced in naïve animals compared to the pain models, indicating that physiological changes such as those mediated by disease states could play a larger role than previously thought in determining neuromodulation outcomes.Significance.Our findings support the continued development of DC neuromodulation as a method for reduction of nociceptive signalling, and suggests that it may be effective at treating a broader range of aberrant pain conditions than existing devices.
Collapse
Affiliation(s)
- Tom F Su
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Jack D Hamilton
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Yiru Guo
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Jason R Potas
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- Eccles Institute, John Curtin School of Medical Research, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Mohit N Shivdasani
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | - Gila Moalem-Taylor
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Gene Y Fridman
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States of America
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States of America
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, United States of America
| | - Felix P Aplin
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
6
|
Crane P, Morris J, Egan W, Young JL, Nova V, Rhon DI. Only 1% of Total Knee Arthroplasty Clinical Trials Report Patient Opioid Use Before or After Surgery: A Systematic Review. Clin J Pain 2023; 39:467-472. [PMID: 37335227 DOI: 10.1097/ajp.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Many clinical trials report significant improvements in osteoarthritis-related pain and function after total knee arthroplasty (TKA). Opioids are commonly prescribed for pain management of knee osteoarthritis and also perioperative pain after surgery. The extent of persistent opioid use after TKA is unknown. Because up to 20% of individuals have poor outcomes after TKA and prior opioid use is a risk factor for future opioid use, treatment effects from TKA clinical trials would be better understood by assessing opioid use data from trial participants. The purpose of this review was to determine the proportion of participants in TKA trials with opioid use before surgery and persistent use after surgery and how well clinical trials capture and report these variables. MATERIALS AND METHODS A systematic review of the literature (5 databases: CINAHL Cochrane CENTRAL, Embase, PubMed, and Web of Science) was conducted to assess the reporting of opioid use in TKA clinical trials. All opioid use was extracted, both prior and postoperatively. Long-term opioid use was determined using 4 different contemporary definitions to increase the sensitivity of the assessment. RESULTS The search produced 24,252 titles and abstracts, and 324 met the final inclusion criteria. Only 4 of the 324 trials (1.2%) reported any type of opioid use; 1 identified prior opioid use, and none reported long-term opioid use after surgery. Only 1% of TKA clinical trials in the past 15 years reported any opioid use. DISCUSSION Based on available research, it is not possible to determine if TKA is effective in reducing reliance on opioids for pain management. It also highlights the need to better track and report prior and long-term opioid use as a core outcome in future TKA trials.
Collapse
Affiliation(s)
- Patricia Crane
- Doctor of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- MossRehab
- Department of Physical Therapy, Temple University
| | - John Morris
- Doctor of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- MossRehab
| | - William Egan
- Doctor of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- Department of Physical Therapy, Temple University
| | - Jodi L Young
- Doctor of Science in Physical Therapy Program, Bellin College, Green Bay, WI
| | - Vitalina Nova
- Charles Library, Temple University, Philadelphia, PA
| | - Daniel I Rhon
- Doctor of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| |
Collapse
|
7
|
VanIderstine C, Johnston E. Risk Factors for Prolonged Opioid Use Following Total Hip Arthroplasty and Total Knee Arthroplasty: A Narrative Review of Recent Literature. Ann Pharmacother 2022:10600280221133078. [DOI: 10.1177/10600280221133078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Objective: To provide pharmacists and other health care professionals with the knowledge required to minimize the risk of prolonged opioid use following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Data Sources: A literature search of PubMed and Embase was performed, and included the search terms: (opioid OR opiate OR opium) AND (risk factor OR predict*) AND (arthroplasty OR replacement) NOT shoulder. Study Selection and Data Extraction: Randomized control trials, cohort studies (both prospective and retrospective), systematic reviews, and meta-analyses were included if risk ratios (RRs) or odds ratios (ORs) were reported and published within the last 5 years. Data Synthesis: ]Twenty studies met inclusion criteria, including 2 meta-analyses and 2 prospective studies. There were several risk factors that overlapped between studies and presented clinically significant risks for prolonged opioid use following THA and TKA surgery. Of these, age < 65 (RRs: 1.15-9.36), preoperative opioid use (RRs: 1.09-7.81), larger quantities of opioids prescribed at discharge (RRs: 1.26-8.81), and TKA surgery (RRs: 1.73-6.07) were the most significant. Several risk factors were recently described, including migraines (RRs: 1.14-5.11) and fibromyalgia (RRs: 1.1-2.3) that may be of interest for further research. Relevance to Patient Care and Clinical Practice: This review presents a discussion of the factors associated with prolonged opioid use following THA and TKA surgeries, which are among the most common orthopedic surgeries. Conclusions: Prescribers should carefully consider patient-specific factors when prescribing opioids as there are several factors, including age, surgery type, and medical conditions that can predispose patients to prolonged opioid use.
Collapse
Affiliation(s)
- Carter VanIderstine
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Pharmacy Department Halifax Infirmary, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Emily Johnston
- Pharmacy Department Halifax Infirmary, Nova Scotia Health, Halifax, Nova Scotia, Canada
| |
Collapse
|