Opioid use prior to knee arthroplasty in patients who catastrophize about their pain: preoperative data from a multisite randomized clinical trial

The Effect of Preoperative Tramadol Use on Postoperative Opioid Prescriptions After Primary Total Hip and Knee Arthroplasty: An Institutional Experience of 11,000 Patients

BACKGROUND

Preoperative opioid use increases opioid consumption postoperatively, but the effect of tramadol is poorly understood.

METHODS

We retrospectively reviewed 11,667 patients undergoing primary unilateral THA and TKA at a single institution. Preoperatively, there were 8,201 opioid-naïve patients (70.3%), 1,315 on tramadol (11.3%), 1,408 on narcotics (12.1%) and 743 on narcotics and tramadol (6.3%). We compared morphine milligram equivalents (MMEs) used during hospitalization, prescribed at discharge, and refilled during the first 90 days. We used multivariate analysis to assess whether preoperative tramadol use was associated with increased number of refills and total refilled MMEs.

RESULTS

Total in-hospital MMEs and daily MMEs was lowest for the opioid naïve patients and significantly increased for the remaining three groups (total in-hospital use: 119, 152, 211, and 196 MMEs, respectively-P < .001) (daily in-hospital use: 66, 74, 100, and 86 MMEs, respectively-P < .001). Opioid refill rate was significantly higher for all patients who were not opioid naïve (32%, 42%, 41%, and 52%, respectively-P < .001). Total MMEs prescribed after discharge was lowest for opioid naïve patients (477, 528, 590 and 658, respectively-P < .001). Logistic and linear regression controlling for age, sex, history of anxiety/depression revealed that THA patients taking tramadol preoperatively were 2.5 times more likely to require post-discharge refills and refilled 80 additional MMEs than opioid naïve patients (P < .001).

CONCLUSION

Tramadol is not recommended for pain beforeTKA or THA, and surgeons and patients should be aware that it is associated with a substantial increase in postoperative opioid use.

Impact of preoperative opioid use on patient-reported outcomes following primary total knee arthroplasty

PURPOSE

The previous literature suggests that 25-30% of patients who undergo total knee arthroplasty (TKA) are using opioids prior to their surgery. This study aims to investigate the effect of preoperative opioid use on clinical outcomes and patient-reported outcome measures (PROMs) following TKA.

METHODS

We retrospectively reviewed 329 patients who underwent primary TKA from 2019 to 2020, answered the preoperative opioid survey, and had available PROMs. Patients were stratified into two groups based on whether they were taking opioids preoperatively or not: 26 patients with preoperative opioid use (8%) and 303 patients without preoperative opioid use (92%) were identified. Demographics, clinical data, and PROMs [Forgotten Joint Score (FJS-12), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR), and Veterans RAND-12 Physical and Mental components (VR-12 PCS and MCS)] were collected. Demographic differences were assessed with Chi-square and independent sample t-tests. Outcomes were compared using multilinear regression analysis, controlling for demographic differences.

RESULTS

Preoperative opioid users had a significantly longer length-of-stay (2.74 vs. 2.10; p = 0.010), surgical time (124.65 vs. 105.69; p < 0.001), and were more likely to be African-American (38.5 vs. 14.2%; p = 0.010) compared to preoperative opioid-naive patients. Postoperative FJS-12 did not statistically differ between the two groups. While preoperative KOOS, JR scores were significantly lower for preoperative opioid users (41.10 vs. 46.63; p = 0.043), they did not significantly differ postoperatively. Preoperative VR-12 PCS did not statistically differ between the groups; however, both 3-month (33.87 vs. 38.41; p = 0.049) and 1-year (36.01 vs. 44.73; p = 0.043) scores were significantly lower for preoperative opioid users. Preoperative VR-12 MCS was significantly lower for preoperative opioid users (46.06 vs. 51.06; p = 0.049), though not statistically different postoperatively.

CONCLUSION

At 8%, our study population had a lower percentage of opioid users than previously reported in the literature. Preoperative opioid users had longer operative times and length of stay compared to preoperatively opioid-naive patients. While both cohorts achieved similar clinical benefits following TKA, preoperative opioid users reported lower postoperative scores with respect to VR-12 PCS scores.

LEVEL III EVIDENCE

Retrospective Cohort.

Use of preoperative opioids increases duration of hospital stay following elective lower limb arthroplasty. - A snapshot of UK practice

This study is one of the first in the UK where to assess the link between pre-operative opioid use and length of stay or complications. The primary objective was to test our hypothesis; that low dose pre-operative opioids will not lead to an increase in complications and LOS in lower limb arthroplasty patients. 640 records were found and 625 patients were included whom received elective primary or revision surgery. It was found that Pre-operative opioids >12 MED does increase LOS.