Characterization of opioid consumption and disposal patterns after total knee arthroplasty

Opioid Consumption After Discharge From Total Knee and Hip Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Pain is challenging after recovery from total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures, and patients often receive prescription opioids. However, opioid consumption by patients remains unclear, and unused opioids may lead to risks including misuse and diversion. The objective of this systematic review and meta-analysis was to compare prescription size versus patient-reported consumption of opioids after discharge following TKA and THA.

METHODS

PubMed and Embase were systematically searched for publications published between 2015 and 2022 on patient-reported consumption of opioids after TKA and THA. The primary outcome was opioid use in oxycodone 5-mg equivalents. Team members independently reviewed studies for screening, inclusion, data extraction, and risk of bias.

RESULTS

Among the 17 included studies (15 TKA and 11 THA), discharge opioid prescribing exceeded consumption for both TKA (88.4 versus 65.0 pills at 6 weeks) and THA (64.0 versus 29.8 pills at 12 weeks). For both TKA and THA, the range of opioids prescribed varied significantly, by 1.6-fold for TKA and 2.8-fold for THA. Most studies reported pain outcomes (89%) and the use of nonopioid medications (72%). Of the 4 studies offering prescribing recommendations, the amounts ranged from 50 to 104 pills for TKA and 30 to 45 pills for THA.

CONCLUSIONS

Opioid prescribing exceeds the amount consumed following TKA and THA. These findings serve as a call to action to tailor prescribing guidelines to how much patients actually consume while emphasizing the use of nonopioid medications to better optimize recovery from surgery.

Perioperative Opioid Use and Dosage Trajectories Vary Depending on Pain Outcome Classification and Bodily Pain in Patients who Catastrophize About Their Pain: A Secondary Analysis of a Randomized Trial in Knee Arthroplasty

Opioid use and dosage following knee arthroplasty (KA) has not been reported for subgroups with persistent moderate pain versus rapidly improving mild pain, externally validated from prior work. We determined if opioid use and dosage varied for persons classified into these externally validated subgroups. A secondary purpose determined if bodily pain scores are associated with the outcome subgroup. This was a secondary analysis of a prospective no-effect randomized clinical trial conducted on 384 participants with pain catastrophizing and scheduled for KA. Data were collected preoperatively and at 2-, 6-, and 12-month following surgery. Two-piece latent class growth curve analyses applied previously validated pain outcomes to determine subgroup outcome trajectories for the proportion of opioid users and oral morphine equivalent (OME) dosages. Substantial trajectory separation was found for opioid use and OME. Specifically, the average OME dosage for the persistent moderate pain subgroup was more than double that for the other outcome subgroup. The average preoperative opioid daily OME dosage for 170 patients reporting opioid use was 24.94 (95% [confidence interval] CI = 20.52, 29.38). Bodily pain was consistently higher for the persistent moderate pain subgroup compared to the other subgroup. Outcome subgroups in patients with pain catastrophizing demonstrated substantial differences in opioid use and dosage and were predicted by high pain catastrophizing, more bodily pain, and changes in bodily pain over time. The persistent moderate pain subgroup is at greater risk of opioid use and greater opioid dosages and should be targeted for preoperative screening and interventions to reduce opioid use and potential opioid misuse. PERSPECTIVE: More frequent and higher opioid dosage following KA was found for the persistent moderate pain subgroup compared to the other subgroup. Patients with persistent pain had worse catastrophizing, contralateral and ipsilateral lower extremity pain, low back pain, and whole body pain compared to the rapidly improving mild pain subgroup.

Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements

BACKGROUND

Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries.

METHODS

We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering.

RESULTS

Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002).

CONCLUSIONS

Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.

Patients prefer free drug disposal options delivered by pharmacists at the point of care: Results of a decision tree analysis of a national factorial vignette panel survey

BACKGROUND

Unused opioid medication in the home increases risk of medication diversion, misuse, and unintended harm. The United States Federal Food and Drug Administration is currently considering the implementation of a risk evaluation and mitigation strategy (REMS) program that would require US pharmacists to provide drug disposal products with opioid prescriptions. Still, little is known about consumer preference for drug disposal method. The objective of this study was to identify product and program characteristics associated with consumer preference for at-home drug disposal products.

METHODS

A 2x2x3x3 full-factorial design was employed to text-based vignettes representing opioid analgesic disposal scenarios. Each vignette varied on four characteristics: product cost (free vs paid), ease of use (a mail back envelope, bringing medication to a takeback site, and an at-home drug deactivation pouch), potential environmental impact (incineration), and point of access (pharmacy, community organization, and prescriber). Of the 36 possible vignettes, 12 were removed as they represented a non-realistic combination of vignette characteristics. The remaining 24 were administered to a panel of patients with controlled-substance use in the past six-months. Decision tree modeling and general linear mixed (GLM) models were used sequentially to identify product characteristics associated with patient drug preferences RESULTS: A total of 1,006 participants completed all vignette drug disposal scenarios. Regression tree analysis found that the most important predictor of use was cost followed by ease of access and product design. GLM showed that takeback programs offered at a pharmacy were the most preferred disposal option followed by at-home products (mailed envelope or deactivation system) dispensed with the prescription.

CONCLUSION

Programs that provide disposal resources directly to the patient at no cost with their prescription are likely to optimize willingness to dispose. Findings support the FDA's plan for a REMS program requiring pharmacies to distribute mail-back envelopes to patients when dispensed opioids.

Long-Term Nonoperative Management is Associated With Lower Mean 9-Year Follow-Up Survival Compared to Total Knee Arthroplasty in Knee Osteoarthritis Patients-Survival Analysis of a Nationwide South Korean Cohort

BACKGROUND

Total knee arthroplasty (TKA) and medications are both considered as a treatment for knee osteoarthritis. However, the impact of the TKA on long-term survival remains controversial. This study aimed to compare 9-year follow-up survival between a TKA group with a nonoperative medication group.

METHODS

From 2007 to 2009, knee osteoarthritis patients were divided into TKA (N = 2,228) and nonoperative medication (N = 76,430) groups, and followed for up to 9 years. The hazard ratio (HR) and subdistribution HR (SHR) were derived from Cox proportional hazards regressions and Fine and Gray analyses, respectively.

RESULTS

The TKA group had a significantly lower adjusted mortality rate (adjusted HR , 0.78, 95% confidence interval [CI], 0.68-0.9) than the nonoperative medication group. Dose-response relationship between medication possession ratio and mortalities for overall (adjusted HR , 1.02; 95% CI, 1.01-1.04) and cardiovascular (CV) death (adjusted SHR, 1.03; 95% CI, 1.01-1.05) was also found. Also, there were significant interactions that indicate stronger protective survival effects of the TKA in several covariates: age >75 years (P = .04 for overall; P = .009 for CV), hypertension (P = .006 for overall), and ischemic heart disease (P = .009 for CV).

CONCLUSIONS

This study suggests that TKA patients had better mean 9-year follow-up survival than the nonoperative medication group after adjusting for baseline differences. For overall death, including CV death, adjusted mortality rates were higher in the medication group and showed a dose-response relationship. Specifically, the protective effect of the TKA for overall or CV deaths was found to be higher for age >75, hypertension, or ischemic heart disease patients.

LEVEL OF EVIDENCE

III.

Opioid Legislation Decreases Opioid Prescribing in Total Knee Arthroplasty

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

Effect of a Medication Disposal Pouch versus Usual Care on Post Discharge Disposal of Unused Opioids: A Randomized Controlled Trial

PURPOSE

To determine frequency of disposal of unused opioids after surgical procedures based on medication disposal pouch use or usual care, and patient factors associated with disposal.

DESIGN

Two-group experimental design and convenience sample.

METHODS

Same-day surgery adults who received opioid orders were randomized to usual care or usual care plus a medication disposal pouch for opioid disposal. Opioid disposal and pain characteristics were collected by telephone at 30±10 days post discharge. Other data were abstracted from a hospital database. Data were compared using Kruskal-Wallis, Pearson's Chi-Square and Fisher's exact tests. Logistic regression models were built to identify predictors of disposal of unused opioids.

FINDINGS

Of 221 adults, mean age was 58.5 years and 50.2% were female. Overall, 121 received medication disposal pouches and 100 received usual care. Among those with a filled prescription, there was no between-group difference in the number of patients who used all of their opioid medication (disposal pouch group, 29.5%; usual care group, 21.7%). Of 74 disposal pouch and 65 usual care patients who did not use all opioid medications, 23.0% and 13.8%, respectively, disposed of opioids, and of the 23.0% of patients who disposed of medications in the disposal pouch group, 94.1% used the medication disposal pouch. After controlling for 7 factors, the odds of disposal of unused opioids increased among patients who received the intervention, had lower pain scores on the worst day of postoperative pain, and had a history of renal diagnoses (versus those with gastrointestinal diagnoses).

CONCLUSIONS

Although opioid medication disposal rates were higher in the medication disposal pouch group; overall rates of disposal of unused opioid medications were low. More research is needed to learn important factors and methods associated with opioid disposal.

Postoperative Pain Medication Utilization in Pediatric Patients Undergoing Sports Orthopaedic Surgery: Characterizing Patient Usage Patterns and Opioid Retention

INTRODUCTION

Opioid overprescribing is a problem in orthopaedic surgery, with many patients having leftover opioid medications after surgery. The purpose of our study was to capture utilization patterns of opioids in pediatric patients undergoing orthopaedic sports medicine surgery, in addition to evaluating patient practices surrounding unutilized opioid medication. Our hypothesis was that there would be low utilization of opioids in this patient population and would in turn contribute to notable overprescribing of opioids and opioid retention in this population.

METHODS

Pediatric patients undergoing orthopaedic surgery for knee and hip pathology were prospectively enrolled. A survey was administered 14 days postoperatively, with questions centered on the patient-reported number of opioids prescribed, number of opioids used, number of days opioids were used, and incidences of leftover opioid medication and disposal of leftover medication. The magnitude of opioid overprescribing was calculated using the reported prescribed and reported used number of opioid pills. Linear regression was used to examine associations between opioids and NSAIDs prescribed.

RESULTS

One hundred fourteen patients reported a mean prescription of 12.0 ± 5.0 pills, with utilization of 4.4 ± 6.1 pills over 2.7 ± 5.1 days. Patients were prescribed 2.73 times the number of opioid pills required on average. One hundred patients (87.7%) reported having unused opioid medication after their surgery, with 71 (71.0%) reporting opioid retention. Regression results showed an association with opioids used and prescribed opioid amount (β = 0.582, R = 0.471, P < 0.001).

DISCUSSION

Overall, our study results help characterize the utilization patterns of opioid medications in the postsurgical pediatric sports orthopaedic population and suggest that orthopaedic surgeons may be able to provide smaller quantities of opioid pills for analgesia than is typically prescribed, which in turn may help reduce the amount of prescription opioid medications present in the community.

LEVEL OF EVIDENCE

Level IV.

The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties

Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.

Influence of perioperative opioid-related patient education: A systematic review and meta-analysis

OBJECTIVE

To determine the role of perioperative protocolized opioid-specific patient education on opioid consumption for individuals undergoing surgical procedures.

METHODS

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) that compared protocolized perioperative opioid-specific patient education to the usual care for adult individuals undergoing surgical interventions. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes.

RESULTS

In total, 15 RCTs that enrolled 2546 participants were deemed eligible. Protocolized opioid-specific patient education showed a significant reduction in postoperative opioid consumption and postoperative pain score compared to usual care (SMD= -0.15, 95% confidence interval [CI]: -0.28 to -0.03 and SMD= -0.17, 95% CI: -0.28 to -0.06, respectively). No significant difference was found between the protocolized opioid-specific patient education and the usual care in terms of the number of refill requests (RR=0.82, 95% CI: 0.50-1.34), patients with opioid leftovers (RR=0.92, 95% CI: 0.78-1.08), and patients taking opioids after hospital discharge.

CONCLUSIONS

This meta-analysis demonstrated that protocolized opioid-specific patient education significantly reduces postoperative opioid consumption and pain score but has no influence on the number of opioid refill requests, opioid leftovers, and opioid use after hospital discharge.

PRACTICE IMPLICATIONS

Healthcare professionals may offer opioid-related educational sessions for the surgical patients during the perioperative period through a video-based material that emphasizes the role of alternative analgesics to opioids, patients' expectations about the post-operative pain, and the potential side effects of opioid consumptions.

Predicting Post-Discharge Opioid Consumption After Total Hip and Knee Arthroplasty in the Opioid-Naïve Patient

BACKGROUND

Pain catastrophizing, anxiety, and depression are associated with poor outcomes after total hip (THA) and total knee (TKA) arthroplasty. The goal of this study is to determine the relationship between post-operative pain scores and opioid consumption; and the association among pre-operative measures of anxiety, depression, and pain catastrophizing and post-operative opioid consumption in patients undergoing THA and TKA.

METHODS

This is a single-institution prospective cohort study of 243 opioid-naïve patients undergoing elective, primary THA (n = 123) or TKA (n = 120) for osteoarthritis. Pre-operatively, patients completed the PROMIS-29 (Patient-Reported Outcomes Measures Information System; physical function/anxiety/depression/fatigue/sleep disturbance/social activities/pain interference/pain intensity) and Pain Catastrophizing Scale. Post-operatively, patients completed a weekly survey for 12 weeks determining morphine-milligram-equivalent (MME) opioid consumption, opioid cessation, and visual analog scale pain scores. Multivariable regression models determined the association between pre-operative scores and post-operative opioid consumption.

RESULTS

Mean (±standard deviation) total opioid consumption and duration was 75.1 ± 112.0 MME and 1.7 ± 1.7 weeks in THA and 384.7 ± 473.3 MME and 4.3 ± 3.5 weeks in TKA. Visual analog scale pain scores (0-100) after opioid cessation were 28.0 ± 22.9 in THA and 30.7 ± 25.8 in TKA. Multivariable regression showed that each unit increase in PROMIS-29 fatigue T-score was associated with 8.4 hours longer opioid usage in THA (P = .008) and 15.1 hours longer in TKA (P = .036), as well as 12.7 MME additional opioids in TKA (P = .027). There were no significant associations with other PROMIS-29 domains or the Pain Catastrophizing Scale.

CONCLUSION

Opioid use duration is different for THA and TKA and may correlate with pain scores. Only pre-operative fatigue was associated with post-operative opioid consumption. These findings should inform THA and TKA post-operative pain management pathways.

The Use of Opioids and Pain Medications in the Management of Postoperative Pain in Total Knee Arthroplasty Patients: A Retrospective Study

Purpose

The opioid crisis amplified the concern for the appropriate use of opioids. Our study aims to investigate the pain levels and amount of opiates needed during the first three days following total knee arthroplasty (TKA), whereby Drug Enforcement Administration (DEA) Schedule II oral opiates are not available.

Methods

A year-long retrospective review of adult patients who underwent TKA was conducted. The postoperative pain scores and mean morphine equivalents (MME) were measured. These outcomes were assessed according to demographics, anesthesia, and analgesia used.

Results

For our 78 patients, there was no statistical difference for stratification by baseline characteristics except in spinal anesthesia, which decreased pain on the first day. Conversely, MME increased to its significantly highest of 14.22 ± 29.58 mg on day 3. The effect was noted for patient-controlled analgesia where patients with intravenous analgesia received less opioid than those on epidural analgesia on postoperative day one.

Conclusions

Using a similar regimen of analgesia, postoperative pain following TKA would be controlled by a relatively low amount of opioids by the third postoperative day. Spinal anesthesia and patient-controlled epidural analgesia were linked to better pain control and less opioid needed.

Early Opioid Consumption Patterns After Anterior Cervical Spine Surgery

STUDY DESIGN

This is a prospective observational study.

OBJECTIVE

The aim was to record daily opioid use and pain levels after 1-level or 2-level anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA).

SUMMARY OF BACKGROUND DATA

Data to inform opioid prescription guidelines following ACDF or CDA is lacking. Understanding postoperative opioid consumption behaviors is critical to provide appropriate postdischarge prescriptions.

METHODS

Patients undergoing 1-level or 2-level primary ACDF or CDA were consecutively enrolled at 2 participating institutions between March 2018 and March 2019. Patients with opioid dependence (defined as daily use ≥6 mo before surgery) were excluded. Starting postoperative day 1, daily opioid use and numeric pain rating scale pain levels were collected through a Health Insurance Portability and Accountability Act-compliant, automated text-messaging system. To facilitate clinical applications, opioid use was converted from oral morphine equivalents into "pills" (oxycodone 5 mg equivalents). After 6 weeks or upon patient-reported cessation of opioid use, final survey questions were asked. Refill data were verified from the state prescription registry. Risk factors for patients in top quartile of consumption were analyzed.

RESULTS

Of 57 patients, 48 completed the daily queries (84.2%). Mean age of the patient sample was 50.2±10.9 years. Thirty-two patients (66.7%) underwent ACDF and 16 CDA (33.3%); 64.6% one level; 35.4% two levels. Median postdischarge use was 6.7 pills (range: 0-160). Cumulative opioid use did not vary between the 1-level and 2-level groups (median pill consumption, 10 interquartile range: 1.3-31.3 vs. 4 interquartile range: 0-18, respectively, P=0.085). Thirteen patients (27.1%) did not use any opioids after discharge. Of those patients that took opioids after discharge, half ceased opioids by postoperative day 8. Preoperative intermittent opioid use was associated with the top quartile of opioid consumption (9.1% vs. 50%, P=0.006).

CONCLUSION

Given that most patients use few opioids, patients could be offered the option of a 12 oxycodone 5 mg (90 oral morphine equivalents) discharge prescription, accompanied by education on appropriate opioid use and disposal.

The Opioid Epidemic in the United States: Where Do Patients Requiring Elective Arthroplasty Stand?

INTRODUCTION

Over the past decade, awareness about opioid abuse in the general community and among prescribers has increased. This study evaluated how opioid prescribing patterns before and after total hip arthroplasty (THA) and total knee arthroplasty (TKA) may have changed during a recent 5-year period.

METHODS

The Truven Health MarketScan database were queried for patients who underwent elective THA and TKA for primary osteoarthritis between 2013 and 2017. The trend analysis evaluated for changes in opioid prescriptions and multivariate regression identified predictors for chronic postoperative opioid use.

RESULTS

Data were available for 27,908 THA patients and 47,220 TKA patients. The proportion of opioid naïve patients before THA or TKA increased significantly (P < 0.001). Median oral morphine equivalents prescribed during the first postoperative year after THA or TKA decreased significantly (P < 0.001). The proportion of patients with chronic postoperative opioid use also decreased for TKA patients (P < 0.001).

DISCUSSION

A notable, downward trend was seen in the proportion of patients who received opioids before elective arthroplasty, in the amount of opioid prescribed after surgery, and in TKA patients, the frequency of chronic opioid use after surgery. These findings reflect the effectiveness of efforts to combat the opioid epidemic after elective arthroplasty surgery.

Older, Male Orthopaedic Surgeons From Southern Geographies Prescribe Higher Doses of Post-Operative Narcotics Than do their Counterparts: A Medicare Population Study

Purpose

Methods

Results

Conclusion

Level of Evidence

Postoperative Pain and Opioid Use after Facial Feminization Surgery

The objective of this study is to characterize surgical pain after facial feminization surgery (FFS) and delineate postoperative opioid usage. It is a retrospective cohort study. It was performed in a multicenter integrated health care system. Electronic medical records were reviewed for patient demographic characteristics, medical history, pain medication prescriptions, and responses to a postoperative pain survey. Student's t-test and the Mann-Whitney U-test were used for bivariate analysis. Fisher's exact tests were used for categorical data. Seventy-four patients who underwent FFS were included. The mean (standard deviation) reported "average" postoperative pain score was 4.3 (2.3) out of 10. A total of 58% of patients reported pain lasting 5 or fewer days after surgery. The severity and duration of postoperative pain was similar between patients who underwent partial-FFS or full-FFS. A total of 68% of patients required fewer than 15 opioid tablets. There were no significant differences in the quantity of opioids prescribed or used between patients who underwent partial-FFS or full-FFS. Older age and premorbid mood disorder did not correlate with greater severity/duration of pain or number of opioids used after surgery. Most patients required fewer than 15 opioid tablets after surgery and experienced less than a week of postoperative pain. Patients undergoing full-FFS did not appear to experience significantly greater pain than those undergoing fewer procedures. Older age and premorbid mood disorder were not predictors of worse pain outcomes or greater opioid utilization.

Changes in opioid discharge prescriptions after primary total hip and total knee arthroplasty affect opioid refill rates and morphine milligram equivalents : an institutional experience of 20,000 patients

AIMS

Due to the opioid epidemic in the USA, our service progressively decreased the number of opioid tablets prescribed at discharge after primary hip (THA) and knee (TKA) arthroplasty. The goal of this study was to analyze the effect on total morphine milligram equivalents (MMEs) prescribed and post-discharge opioid repeat prescriptions.

METHODS

We retrospectively reviewed 19,428 patients undergoing a primary THA or TKA between 1 February 2016 and 31 December 2019. Two reductions in the number of opioid tablets prescribed at discharge were implemented over this time; as such, we analyzed three periods (P1, P2, and P3) with different routine discharge MME (750, 520, and 320 MMEs, respectively). We investigated 90-day refill rates, refill MMEs, and whether discharge MMEs were associated with represcribing in a multivariate model.

RESULTS

A discharge prescription of < 400 MMEs was not a risk factor for opioid represcribing in the entire population (p = 0.772) or in opioid-naïve patients alone (p = 0.272). Procedure type was the most significant risk factor for narcotic represcribing, with unilateral TKA (hazard ratio (HR) = 5.62), bilateral TKA (HR = 6.32), and bilateral unicompartmental knee arthroplasty (UKA) (HR = 5.29) (all p < 0.001) being the highest risk for refills. For these three procedures, there was approximately a 5% to 6% increase in refills from P1 to P3 (p < 0.001); however, there was no significant increase in refill rates after any hip arthroplasty procedures. Total MMEs prescribed were significantly reduced from P1 to P3 (p < 0.001), leading to the equivalent of nearly 500,000 fewer oxycodone 5 mg tablets prescribed.

CONCLUSION

Decreasing opioids prescribed at discharge led to a statistically significant reduction in total MMEs prescribed. While the represcribing rate did not increase for any hip arthroplasty procedure, the overall refill rates increased by about 5% for most knee arthroplasty procedures. As such, we are now probably prescribing an appropriate amount of opioids at discharge for knee arthroplasty procedure, but further reductions may be possible for hip arthroplasty procedures. Cite this article: Bone Joint J 2021;103-B(7 Supple B):103-110.

Reduction of Opioid Quantities at Discharge After TKA Did Not Increase the Risk of Manipulation Under Anesthesia: An Institutional Experience

BACKGROUND

In response to the opioid epidemic, our arthroplasty service sequentially reduced the opioid quantities prescribed at primary total knee arthroplasty (TKA) discharge. However, its effect on postdischarge pain control and rehabilitation is unknown. We assessed if this decrease was associated with an increase in the risk of manipulation under anesthesia (MUA).

METHODS

We retrospectively reviewed 8799 patients undergoing primary TKA from 2016 to 2019 at a single institution. There were two institution-wide reductions in the amount of opioids prescribed at discharge; therefore, we divided patients into 3 periods (P1, P2, and P3). The mean discharge morphine milligram equivalents (MMEs) went from 900 MMEs to ~525 MMEs to ~320 MMEs in P1, P2, and P3, respectively. We analyzed MUA rates and if lower discharge MMEs was a risk factor for MUA in a multivariate model. We also compared refill patterns (rates, number, refill MMEs, and total MMEs) between MUA and non-MUA patients.

RESULTS

The rate of MUA did not increase with reduced discharged opioids (5.5% in P1, 5.8% in P2, and 4.6% in P3, P = .74). In a multivariate analysis, discharge MMEs of <450 was not a significant risk factor for MUA. However, a diagnosis of chronic pain (OR = 1.86, P < .001) and an elevated body mass index (OR = 1.02 per unit increase, P < .001) were significant risk factors. We did not find significant differences in any opioid prescription refill patterns in MUA and non-MUA patients.

CONCLUSION

Serial reductions in discharge MMEs after primary TKA did not significantly affect the rate of MUA, a surrogate marker for pain control and the rehabilitative process.

An opioid-sparing protocol with intravenous parecoxib can effectively reduce morphine consumption after simultaneous bilateral total knee arthroplasty

Multimodal pain management protocol effectively relieves pain following simultaneous bilateral total knee arthroplasty (SBTKA) but is associated with administration of large amounts of opioids in the perioperative period. In this prospective, randomized, assessor-blinded, single-surgeon clinical trial, the goal was to validate the efficacy of an opioid-sparing protocol for SBTKA with a reduced opioid dose, while achieving similar pain relief with few adverse events. Fifty-six patients who had undergone SBTKA were randomly allocated to receive either an opioid-sparing or opioid-based protocol. The primary outcome parameters were visual analogue scale (VAS) scores at rest, with movement, and cumulative morphine dose, through time. Secondary outcome parameters included drug-related adverse events and range of motion with continuous passive motion device, through time. In the opioid-sparing group, a lower VAS score with movement at postoperative 24 and 72 h was observed compared with the opioid-based group, but the difference did not reach the minimal clinically importance difference. A reduced cumulative morphine dose was noted in the opioid-sparing group at postoperative 24, 48 and 72 h. In conclusion, the opioid-sparing protocol may be used as an alternative modality for pain management following SBTKA. Similar pain relief effects may be achieved utilizing a reduced cumulative opioid dose, with few opioid related adverse events.

Narcotic Refills and Patient Satisfaction With Pain Control After Total Joint Arthroplasty

BACKGROUND

Patient satisfaction has become an important metric for total joint arthroplasty (TJA) used to reimburse hospitals. Despite ubiquitous narcotic use for post-TJA pain control, there is little understanding regarding patient factors associated with obtaining opioid refills and associations with patient satisfaction.

METHODS

Using our state's mandatory opioid prescription monitoring program, we reviewed preoperative and postoperative narcotic prescriptions filled for 438 consecutive TJA patients. Subjects were divided into 3 groups based on the number of post-TJA narcotic refills obtained (0, 1, or >1), and logistic regression analysis was conducted comparing demographics, surgical factors, and satisfaction with pain control.

RESULTS

One hundred twenty-five patients (25.8%) did not consume preoperative opioids and received no postoperative refills. Total hip arthroplasty (THA) patients (P = .0004), subjects ≥65 years (P = .0057), and Medicare patients (P = .0058) had significantly higher rates of 0 postdischarge refills. THA recipients had 268% increased odds of not receiving a refill narcotic (adjusted odds ratio = 0.373; 95% confidence interval, 0.224- 0.622). Every 100-morphine milligram equivalent (MME) increase in presurgery use led to a 16% increase in odds of needing >1 opioid refill (adjusted odds ratio = 1.161; 95% confidence interval, 1.085-1.242). Subjects who noted higher satisfaction consumed less overall opioids when receiving a refill (436 vs 1119 MMEs, P = .021).

CONCLUSION

Subjects who received fewer narcotic prescriptions and overall MMEs demonstrated higher rates of satisfaction with early pain control. Our results are consistent with other studies in showing that increased preoperative narcotic use portends higher rates of postoperative refills. There appears to be a subset of THA patients >65 years of age who may be candidates for opioid-sparing analgesia.

Reduction of Opioids Prescribed Upon Discharge After Total Knee Arthroplasty Significantly Reduces Consumption: A Prospective Study Comparing Two States

BACKGROUND

Opioids prescribed for acute pain after total knee arthroplasty (TKA) play a contributing role in the number of opioid pills in circulation. At the height of an opioid epidemic in the United States, opioids are increasingly diverted, misused, and abused. Therefore, many states have enacted narcotic regulations in an attempt to curb opioid diversion and misuse. The purpose of this study is to evaluate the effect of stricter state prescribing regulations on opioid consumption following TKA.

METHODS

In total, 165 opioid-naive patients undergoing primary unilateral TKA at a single institution with a standardized perioperative pain protocol were reviewed. Seventy-one patients (group 1) resided in a state with strict opioid regulations that limit the initial number of pills dispensed and refills, whereas 92 patients (group 2) resided in another state without quantity and refill regulations. Patient demographics were similar between the 2 groups. Mean age was 64 and mean body mass index was 32 kg/m². Opioid consumption, quantity, and refill patterns were collected for 6 weeks following surgery.

RESULTS

The average oral morphine equivalents consumed during the 6 weeks postsurgery were significantly lower in group 1 at 446.3 ± 266.3 mg (range 10-992) compared to group 2 at 622.6 ± 313.7 mg (range 20-1416) (P < .001). The average oral morphine equivalent corresponds to 60 tablets of 5 mg oxycodone per patient in group 1 vs 84 tablets per patient in group 2. Fifty-nine (83%) patients in group 1 had stopped taking opioids within 6 weeks of surgery compared to 59 (64%) in group 2 (P = .04).

CONCLUSION

Based on our results, the institution of state regulations aimed at decreasing the quantity and refills of postoperative opioids led patients to consume less opioids following TKA. Many patients are prescribed more opioids than they require which increases their consumption and can increase the risk for diversion, addiction, and misuse.

LEVEL OF EVIDENCE

Level III; retrospective comparative cohort study.

Inpatient and outpatient opioid requirements after total joint replacement are strongly influenced by patient and surgical factors

Aims

Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty.

Methods

Outcomes after 92 primary total knee (n = 49) and hip (n = 43) arthroplasties were analyzed. Patients with repeat surgery within 90 days were excluded. Opioid use was recorded while inpatient and 90 days postoperatively. Outcomes included total opioid use, refills, use beyond 90 days, and unplanned clinical encounters for uncontrolled pain. Multivariate modelling determined the effect of surgery, regional nerve block (RNB) or neuraxial anesthesia (NA), and non-opioid medications after adjusting for demographics, ength of stay, and baseline opioid use.

Results

TKAs had higher daily inpatient opioid use than THAs (in 5 mg oxycodone pill equivalents: median 12.0 vs 7.0; p < 0.001), and greater 90 day use (median 224.0 vs 100.5; p < 0.001). Opioid refills were more likely in TKA (84% vs 33%; p < 0.001). Patient who underwent TKA had higher independent risk of opioid use beyond 90 days than THA (adjusted OR 7.64; 95% SE 1.23 to 47.5; p = 0.01). Inpatient opioid use 24 hours before discharge was the strongest independent predictor of 90-day opioid use (p < 0.001). Surgical procedure, demographics, and baseline opioid use have greater influence on in/outpatient opioid demand than RNB, NA, or non-opioid analgesics.

Conclusion

Opioid use following TKA and THA is most strongly predicted by surgical and patient factors. TKA was associated with higher postoperative opioid requirements than THA. RNB and NA did not diminish total inpatient or 90-day postoperative opioid consumption. The use of acetaminophen, gabapentin, or NSAIDs did not significantly alter inpatient opioid requirements.

Cite this article: Bone Joint Open 2020;1-7:398–404.

Prospective cohort study of opioid use after total knee arthroplasty in a single center

OBJECTIVES

Fewer opioids prescribed for postoperative pain may help reduce the number of surplus opioids available in the community and decrease the risk of opioid dependence. Published data on patients' opioid use after total knee arthroplasty (TKA) are limited.

METHODS

This was a prospective study designed to characterize opioid use after TKA. Patients who have undergone TKA and met inclusion criteria were recruited to complete a survey after orthopedic surgeon follow-up appointments approximately 2 and 6 weeks postoperatively. Questions included satisfaction with pain management strategies, type and quantity of medication prescribed, and quantity of leftover medication. Additional data on opioid use and baseline characteristics were determined through chart review.

RESULTS

A total of 60 patients completed surveys after TKA. All patients spent at least 1 night in the hospital or skilled nursing facility with an average length of stay of 1.2 days and an average consumption of 5.2 tablets of oxycodone 5 mg equivalents. After discharge, the mean number of oxycodone 5 mg tablet equivalents prescribed in the initial prescription was 38.6, with an average of 72.6 prescribed over 6 weeks. Patients reported an average of 15.7 unused oxycodone 5 mg tablet equivalents.

CONCLUSION

These results could help guide the development of TKA-specific opioid prescribing guidelines and confirm that patients are generally prescribed more opioids than they consume.

Combating the Opioid Epidemic: Experience with a Single Prescription for Total Joint Arthroplasty

Background

Despite advances in perioperative total joint arthroplasty (TJA) pain protocols, opiates continue to play a major role in postoperative pain control. This brief communication reports our experience with a restrictive opioid protocol allowing patients only a single prescription of low-dose opioids.

Methods

One hundred consecutive elective, primary, and revision TJAs were analyzed. All patients received preoperative counseling and multimodal analgesia. Counseling involved discussion of patient expectations on postoperative pain management, weaning off opioids before surgery, and emphasis that opioid refills were not permitted. Ninety-day outcomes including pain-related phone calls, opioid refill requests, emergency room visits, complications, and readmissions were assessed. Opioid dispensing was tracked using our state prescription monitoring program.

Results

There was a high prevalence of preoperative opioid use, depression, and anxiety (25%, 34%, and 39%, respectively). Sixty-eight percent of chronic opioid users were able to wean off opioids before surgery. The average initial prescription of opioids was equivalent to 48 pills of 5 mg oxycodone. There were only 10 pain-related phone calls from 9 patients; all were using opioids preoperatively, with only one patient requesting a refill. All pain-related phone calls occurred in the first week after surgery. There were no emergency room visits, complications, or readmissions related to pain.

Conclusions

A single prescription of low-dose opioids was sufficient for patients undergoing TJA when using preoperative patient preparation and multimodal analgesia. Standardized guidelines are needed to guide best practices for patient education and pain management, especially in patients on chronic opioid therapy. This information will help implement evidence-based strategies to accelerate the decline of opioid use and hopefully pave the way for opioid-free TJA.

Education Increases Disposal of Unused Opioids After Total Joint Arthroplasty: A Cluster-Randomized Controlled Trial

BACKGROUND

Unused opioid pills are a danger to patients and their loved ones as they may be diverted for abuse or misuse. The purpose of this study was to determine the baseline rate of proper disposal of unused opioids among patients undergoing total joint arthroplasty and to determine how education impacts disposal rates.

METHODS

In this study, 563 patients undergoing primary total joint arthroplasty (183 patients undergoing total hip arthroplasty, 293 patients undergoing total knee arthroplasty, and 87 patients undergoing unicompartmental knee arthroplasty) were cluster-randomized to groups that received no education, educational pamphlets, or educational pamphlets plus text messages. Patients were randomized by education class and were blinded to participation to avoid behavioral modifications. Patients were surveyed at 6 weeks postoperatively to determine if they disposed of their unused opioid pills using a U.S. Food and Drug Administration-recommended method, which was the primary outcome. Assuming a 15% difference in opioid disposal rates as clinically relevant, power analysis determined that 76 patients with unused opioids were required per group (228 total). An as-treated analysis was conducted with the Fisher exact text and analysis of variance with alpha = 0.05.

RESULTS

A total of 539 patients (95.7%) completed the survey, and 342 patients (63.5%) had unused opioid pills at 6 weeks postoperatively: 89 patients in the no education group, 128 patients in the pamphlet group, and 125 patients in the pamphlet and text message group. Of these 342 patients, 9.0% of patients in the no education group, 32.8% of patients in the pamphlet group, and 38.4% of patients in the pamphlet and text message group properly disposed of their unused opioids (p = 0.001 for each educational intervention compared with no education). Unused opioid pills were kept by 82.0% of patients in the no education group, 64.1% of patients in the pamphlet group, and 54.4% of patients in the pamphlet and text message group (p < 0.001 for the no education group compared with either educational strategy group). Patients who underwent total hip arthroplasty were more likely to properly dispose of their unused opioids compared with those who underwent total knee arthroplasty (odds ratio, 2.1; p = 0.005). There were no demographic differences between groups, including inpatient opioid use, refills, and preoperative opioid use, other than sex (41.5% male patients in the no education group, 55.0% male patients in the pamphlet group, and 37.4% male patients in the pamphlet and text message group; p = 0.001), suggesting appropriate randomization.

CONCLUSIONS

The rate of opioid disposal is very low after total joint arthroplasty. Education on opioid disposal more than triples opioid disposal rates compared with no education. To help to prevent diversion of unused opioid pills, all patients who undergo total joint arthroplasty should be educated on the proper disposal of unused opioids.

Use of Tetrahydrocannabinol and Cannabidiol Products in the Perioperative Period Around Primary Unilateral Total Hip and Knee Arthroplasty

BACKGROUND

Given the opioid crisis in America, patients are trying alternative medications including tetrahydrocannabinol (THC) and other cannabidiol (CBD) containing products in the perioperative period, especially in states where these products are legal. This study sought to analyze usage rates of CBD/THC products in the perioperative period for primary unilateral total hip and knee arthroplasty (THA/TKA) patients and identify a possible association with post-operative opioid use.

METHODS

A prospective cohort of primary unilateral THA/TKA patients were enrolled at a single institution. Patients who completed detailed pain journals were retrospectively surveyed for CBD/THC product usage. Pain medications were converted to morphine milligram equivalents (MME).

RESULTS

Data from 195 of the 210 patients (92.9% response rate) following primary arthroplasty were analyzed. Overall, 16.4% of arthroplasty-22.6% (n = 19) of TKA and 11.7% (n = 13) of THA-patients used CBD/THC products in the perioperative period. There was a wide variety of usage patterns among those using CBD/THC products. In comparing CBD/THC users and non-users, there was no significant difference in the length of narcotic use, total morphine milligram equivalents taken, narcotic pills taken, average post-op pain scores, the percentage of patients requiring a refill of narcotics, or length of stay.

CONCLUSION

Understanding that CBD/THC usage was not consistent for patients who used these products, 22.6% of TKA and 11.7% of THA patients tried CBD/THC products in the perioperative period. In this small sample, CBD/THC use was not associated with a major effect on narcotic requirements. Further studies on the effects of CBD/THC are needed as these therapies become more widely available.

Opioid Use After Discharge Following Primary Unilateral Total Hip Arthroplasty: How Much Are We Overprescribing?

BACKGROUND

The opioid crisis pressures orthopedic surgeons to reduce the amount of narcotics prescribed for postoperative pain management. This study sought to quantify postoperative opioid use after hospital discharge for primary unilateral total hip arthroplasty (THA) patients.

METHODS

A prospective cohort of primary unilateral THA patients were enrolled at a single institution. Detailed pain journals tracked all prescription and over-the-counter pain medication, quantity, frequency, and visual analog scale pain scores. Pain medications were converted to morphine milligram equivalents (MME).

RESULTS

Data from 121 subjects were analyzed; the average visual analog scale pain score was 3.44 while taking narcotics. The average number of days taking narcotics was 8.46 days. The distribution of days taking narcotics was right shifted with 50.5% of patients off narcotics after 1 week, and 82.6% off by 2 weeks postoperatively. The average number of narcotic pills prescribed was significantly greater than narcotic pills taken (72.5 vs 28.8, P < .0001). The average MME prescribed was significantly greater than MME taken (452.1 vs 133.8, P < .0001). The average excess narcotic pills prescribed per patient was 51.7 pills. And 71.9% took fewer than 30 narcotic pills; 90.9% patients took fewer than 50 narcotic pills. Also, 10.7% did not require any narcotics; 9.9% required a refill of narcotics; and 33.1% went home the day of surgery.

CONCLUSION

Significantly more narcotics were prescribed than were taken in the postoperative period following THA with an average 51.7 excess narcotic pills per patient. Adjusting prescribing patterns to match patient narcotic usage could reduce the excess narcotic pills following THA.

Opioid Use After Discharge Following Primary Unilateral Total Knee Arthroplasty: How Much Are We Over-Prescribing?

BACKGROUND

The opioid crisis pressures orthopedic surgeons to reduce the amount of narcotics prescribed for post-operative pain management. This study sought to quantify post-operative opioid use after hospital discharge for primary unilateral total knee arthroplasty (TKA) patients.

METHODS

A prospective cohort of primary unilateral TKA patients performed by one of 5 senior fellowship-trained arthroplasty surgeons were enrolled at a single institution. Detailed pain journals tracked all prescriptions and over-the-counter pain medications, quantities, frequencies, and visual analog scale pain scores. Narcotic and narcotic-like pain medications were converted to morphine milligram equivalents (MME). Statistical analysis was performed using Student's t-test with α < 0.05.

RESULTS

Data from 89 subjects were analyzed; the average visual analog scale pain score was 6.92 while taking narcotics. The average number of days taking narcotics was 16.8 days. The distribution of days taking narcotics was right shifted with 52.8% of patients off narcotics after 2 week, and 74.2% off by 3 weeks post-op. The average MME prescribed was significantly greater than MME taken (866.6 vs 428.2, P < .0001). The average number of narcotic pills prescribed was significantly greater than narcotic pills taken (105.1 vs 52.0, P < .0001). The average excess narcotic pills prescribed per patient was 53.1 pills. About 48.3% took fewer than 40 narcotic pills; 75.3% took fewer than 75 narcotic pills. About 3.4% did not require any narcotics; 40.5% required a refill of narcotics. Also, 9.0% went home the day of surgery.

CONCLUSION

Significantly more narcotics were prescribed than were taken in the post-operative period following TKA with an average 53.1 excess narcotic pills per patient. Adjusting prescribing patterns to match patient narcotic usage could reduce the excess narcotic pills following TKA.

What Happens to Unused Opioids After Total Joint Arthroplasty? An Evaluation of Unused Postoperative Opioid Disposal Practices

BACKGROUND

This study evaluates the fate of unused opioids after total hip arthroplasty (THA) and total knee arthroplasty (TKA) at our facility.

METHODS

Medication disposal after primary elective THA and TKA was classified as appropriate (in accordance with United States Food and Drug Administration guidelines) or inappropriate for all patients undergoing these procedures during the second half of the fiscal year 2015.

RESULTS

In total, 199 THAs and 144 TKAs met inclusion criteria. Total pills prescribed were 55,635. Approximately 8925 (16%) of pills were unused. About 39.9% of patients disposed of unused opioids appropriately, while 60.1% of patients reported still having (18.5%), not knowing where they were (8.2%), or other (33.4%). There was no significant association with the type of opioid prescribed.

CONCLUSION

A large volume of unused opioids were improperly disposed of after total joint arthroplasty.