Opioids in Arthroplasty: Mind the Gap Between North America and the Rest of the World

Greater Mental Health Burden is Associated With Poor Postoperative Pain Control and Increased Opioid Utilization Following Total Shoulder Arthroplasty

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.

Dexamethasone as additive of local infiltration analgesia reduces opioids consumption after simultaneous bilateral total hip or knee arthroplasty: a randomized controlled double-blind trial

PURPOSE

A randomized controlled double-blind trial was conducted to evaluate the effects of adding dexamethasone to the local infiltration analgesia (LIA) mixture on frequency of patient controlled analgesia (PCA) and opioids consumption after simultaneous bilateral total hip or knee arthroplasty (THA or TKA).

METHODS

108 patients who received simultaneous bilateral THA or TKA were randomly divided into dexamethasone group and normal saline (NS) group. The main difference between two groups was whether or not dexamethasone was added to the LIA mixture. The main outcome was the cumulative consumption of opioids within 24 h. The secondary outcome were the total cumulative consumption of opioids during postoperative hospitalization, consumption of opioids drug for rescue analgesia, frequency of PCA, postoperative Visual Analogue Scale (VAS), and complications.

RESULTS

Cumulative consumption of opioids in the 24 h was similar between two groups (P = 0.17). Total cumulative consumption of opioids in the dexamethasone group during postoperative hospitalization was significantly lower (P = 0.03). No significant difference in the consumption of opioids drug for rescue analgesia between two groups within 24 h, while the frequency of PCA was significantly different (P = 0.04). VAS of dexamethasone group and NS group were similar during postoperative hospitalization, while the incidence of postoperative nausea and vomiting (PONV) in dexamethasone group was lower than that in NS group.

CONCLUSIONS

Adding dexamethasone to LIA in the simultaneous bilateral THA or TKA can effectively reduce the total cumulative consumption of opioids and the frequency of PCA, as well as reduce the incidence of PONV. Trial Registration The trial has been registered in the Chinese Clinical Trial Registry (Registration Number: ChiCTR2100042551, Date: 23/01/2021).

Early Opiate Analgesic Requirements Following Nonsurgically Managed Tibial Fractures in Children

BACKGROUND

Many children with tibial fractures are currently being managed as outpatients. It is unclear how much opiates should be prescribed to ensure adequate analgesia at home without overprescription. This study aimed to evaluate the risk factors for requiring opiates following admission for tibial fractures and to estimate opiate requirements for children being discharged directly from the emergency department (ED).

METHODS

All children aged 4 to 16 years admitted with closed tibial fractures being treated in a molded circumferential above-knee plaster cast between October 2015 and April 2020 were included. Case notes were reviewed to identify demographics, analgesic prescriptions, and complications. Risk factors were analyzed using logistic regression.

RESULTS

A total of 75 children were included, of which 64% were males. The mean age was 9.5 (SD 3.4) years. Opiates were required by 36 (48%) children in the first 24 hours following admission. The median number of opiate doses in the first 48 hours was 0 (range: 0 to 5), with 93% of children receiving ≤3 doses. The odds of requiring opiates in the first 24 hours were unchanged for age above 10 years [odds ratio (OR)=0.85, 95% confidence interval (CI): 0.33-2.23], male sex (OR=1.58, 95% CI: 0.59-4.19), high-energy injury (OR=1.65, 95% CI: 0.45-6.04), presence of a fibula fracture (OR=2.21, 95% CI: 0.72-6.76), or need for fracture reduction in the ED (OR=0.57, 95% CI: 0.20-1.65). No children developed compartment syndrome, and the mean length of stay was 1.4 (SD 1.2) days. No children were readmitted following discharge.

CONCLUSIONS

We have found no cases of compartment syndrome or extensive requirement for opiates following closed tibial fractures treated in plaster cast. These children are candidates to be discharged directly from the ED. We have not identified any specific risk factors for the targeting of opiate analgesics. We recommend a guideline prescription of 6 doses of opiates for direct discharge from the ED to ensure adequate analgesia without overprescription.

LEVEL OF EVIDENCE

Level IV-case series.

Effect of preoperative long-term opioid therapy on patient outcomes after total knee arthroplasty: an analysis of multicentre population-based administrative data

Background

Up to 40% of patients are receiving opioids at the time of total knee arthroplasty (TKA) in the United States despite evidence suggesting opioids are ineffective for pain associated with arthritis and have substantial risks. Our primary objective was to determine whether preoperative opioid users had worse knee pain and physical function outcomes 12 months after TKA than patients who were opioid-naive preoperatively; our secondary objective was to determine the prevalence of opioid use before and after TKA in Alberta, Canada.

Methods

In this retrospective analysis of population-based data, we identified adult patients who underwent TKA between 2013 and 2015 in Alberta. We used multivariable linear regression to examine the association between preoperative opioid use and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function scores 12 months after TKA, adjusting for potentially confounding variables.

Results

Of the 1907 patients, 592 (31.0%) had at least 1 opioid dispensed before TKA, and 124 (6.5%) were classified as long-term opioid users. Long-term opioid users had worse adjusted WOMAC pain and physical function scores 12 months after TKA than patients who were opioid-naive preoperatively (pain score β = 7.7, 95% confidence interval [CI] 4.0 to 11.6; physical function score β = 7.8, 95% CI 4.0 to 11.6; p < 0.001 for both). The majority (89 ([71.8%]) of patients who were long-term opioid users preoperatively were dispensed opioids 180–360 days after TKA, compared to 158 (12.0%) patients who were opioid-naive preoperatively.

Conclusion

A substantial number of patients were dispensed opioids before and after TKA, and patients who received opioids preoperatively had worse adjusted pain and functional outcome scores 12 months after TKA than patients who were opioid-naive preoperatively. These results suggest that patients prescribed opioids preoperatively should be counselled judiciously regarding expected outcomes after TKA.

Perioperative dexamethasone administration reduces 'on-demand' opioid requirements in bilateral total hip arthroplasty

BACKGROUND

Bilateral joint arthroplasty is currently not common, but its usage is expected to increase in the future. This may result in larger amounts of opioids being consumed by patients due to anticipated increased pain and prolonged recovery from this procedure.

AIM

We describe the impact of perioperative steroid administration in a cohort of bilateral total hip arthroplasties (THAs) (44 hips) in relation to post-operative opioid consumption.

METHODS

We report a single-surgeon consecutive case series of simultaneously performed bilateral THAs. Nine patients received two doses of 8 mg IV dexamethasone in the perioperative setting. There were 13 patients in the control group that received no dexamethasone. The primary outcome measure was post-operative analgesic requirements (mg/mcg). Secondary outcomes included post-operative pain according to the visual analogue score (VAS), anti-emetic requirements (mg) and length of stay (days).

RESULTS

The mean 'on-demand' Oxynorm® (IR oxycodone) usage in the 'steroid' group was lower than the 'non-steroid' group (47 mg vs 111 mg) (p = 0.005). There was also a significant decrease in the mean consumption of pregabalin in the 'steroid' group when compared with the 'non-steroid' group-464 mg versus 570 mg (p = 0.000). There was no reduction in the requirement of 'regularly' prescribed opioid analgesic medications. VAS analysis demonstrated no significant difference between the two groups at any timepoint. The 'steroid' group did have a trend towards a lower total LOS at 4.6 days compared with 5.5 days in the 'non-steroid' group (p = 0.0503).

CONCLUSIONS

We recommend the use of perioperative steroids in bilateral THA to reduce the consumption of potentially problematic opioid-based analgesics.

Reducing Opioid Prescriptions Lowers Consumption Without Detriment to Patient-Reported Pain Interference Scores After Total Hip and Knee Arthroplasties

BACKGROUND

Opioid addiction is endemic in the United States. We developed a standardized opioid-prescribing schedule (SOPS) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and evaluated opioid usage alongside Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference scores. We hypothesized that opioid usage would be less than prescribed and reducing prescription would decrease consumption without negatively impacting the PROMIS scores.

METHODS

A prospective observational study was performed on all patients undergoing primary THA and TKA from April 7, 2018, to August 10, 2019. Opioid consumption and pain interference were determined 2 weeks after discharge via telephone and email surveys. SOPSs were implemented during the study. Outcomes were compared in patients before and after the SOPS.

RESULTS

A total of 715 patients met inclusion criteria; 201 patients completed surveys. Before the SOPS, the mean opioid prescription was 81.2 ± 15.3 tablets for THA and 82.9 ± 10.6 for TKA. The mean usage was 35.1 ± 29.4 tablets and 35.4 ± 33.4, respectively. After the SOPS, the mean usage decreased to 19.4 ± 16.8 (P = .04) and 31.6 ± 20.9 (P = .52), respectively. After implementation of a second SOPS for THA, the mean number of tablets consumed was 21.5 ± 18.6 (P = .05 compared with pre-SOPS). The PROMIS 6B responses in patients who underwent THA demonstrated no significant changes. PROMIS 6B responses for TKA showed an increase in interference with recreational activities (P = .04) and tasks away from home (P = .04), but otherwise had no significant impact on reported scores.

CONCLUSIONS

Implementation of the SOPS reduced postoperative opioid prescription and consumption without significantly impacting the reported pain interference, supporting the need to decrease opioid prescription after THA and TKA.

Perioperative steroid administration improves knee function and reduces opioid consumption in bilateral total knee arthroplasty

INTRODUCTION

The benefits of steroid usage have been well described for unilateral total knee arthroplasty (TKA), however it's benefits in bilateral TKA has not been well published in the literature. We describe the impact of perioperative steroid administration in a cohort of bilateral TKAs (74 knees) with regard to immediate postoperative knee function, postoperative knee strength and opioid consumption.

MATERIALS AND METHODS

We report on a single-surgeon consecutive case series of simultaneously-performed bilateral TKAs. Eighteen patients received 2 doses of 8 mg IV dexamethasone in the perioperative setting. There were 19 patients in the control group. Primary outcome measures were day 1 postoperative knee flexion (degrees), knee strength and postoperative analgesic requirements (mg/mcg). Morphine dose equivalents (MDE) were calculated to compare all opioid-based analgesics. Secondary outcomes included post-operative pain according to the VAS (at 24, 48 and 72 h), anti-emetic requirements (mg) and length of stay (days).

RESULTS

The mean knee flexion achieved day 1 in the steroid group was 70.1°(σ = 17.64, 95% CI 64.1-76.0) compared to 55.8° in the non-steroid group (σ = 19.8, 95% CI 49.2-62.3) (p = 0.0008). Regarding the straight leg raise, 88.9% of the steroid group were able to achieve this compared to only 55.2% of the non-steroid group (p = 0.002). There was a reduction in the MDE requirement per patient across all medications for the 'steroid' group. Both Targin® (p = 0.03) (Prolonged-Release Oxycodone) and Fentanyl (p = 0.01) requirements were significantly reduced in the 'steroid' group.

CONCLUSION

We recommend the use of perioperative steroids in bilateral TKA to allow accelerated rehabilitation, improved immediate knee function and an overall reduction in the consumption of potentially problematic opioid-based analgesics.

The Variable Effects of NSAIDs on Osteotomy Healing and Opioid Consumption

In an effort to fight the opioid epidemic, an NSAID pain protocol was created for osteotomy patients. The study asked if NSAIDs negatively affect bone healing or reduce the need for opioids.

Development and validation of machine learning algorithms for postoperative opioid prescriptions after TKA

Objective

The aims of this study were to develop machine learning algorithms for preoperative prediction of prolonged opioid prescriptions after TKA and to identify variables that can predict the probability of this adverse outcome.

Methods

Five algorithms were developed for prediction of prolonged postoperative opioid prescriptions.

Results

The stochastic gradient boosting (SGB) model had the best performance. Age, history of preoperative opioid use, marital status, diagnosis of diabetes, and several preoperative medications were predictive of prolonged postoperative opioid prescriptions.

Conclusion

The SGB algorithm developed could help improve preoperative identification of TKA patients at risk for prolonged postoperative opioid prescriptions.

Integrated clinical pathways with watertight, multi-layer closure to improve patient outcomes in total hip and knee joint arthroplasty

The number of primary total hip and knee replacement surgeries is increasing primarily due to an aging population. There is also a concomitant increase in the number of complications which could be attributed to high variation in arthroplasty techniques, peri-operative methods and the absence of integrated clinical pathways (ICP) to mitigate risks such as surgical site infections (SSIs). The implementation of ICPs incorporating watertight, multi-layer closure could increase the preventative effectiveness against joint prosthetic adverse events. The objective of this review is to describe the ICPs implemented by one US facility to help address ten adverse events synergistically.