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Prentice HA, Harris JE, Sucher K, Fasig BH, Navarro RA, Okike KM, Maletis GB, Guppy KH, Chang RW, Kelly MP, Hinman AD, Paxton EW. Improvements in Quality, Safety and Costs Associated with Use of Implant Registries Within a Health System. Jt Comm J Qual Patient Saf 2024; 50:404-415. [PMID: 38368191 DOI: 10.1016/j.jcjq.2024.01.011] [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: 08/04/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Clinical quality registries (CQRs) are intended to enhance quality, safety, and cost reduction using real-world data for a self-improving health system. Starting in 2001, Kaiser Permanente established several medical device CQRs as a quality improvement initiative. This report examines the contributions of these CQRs on improvement in health outcomes, changes in clinical practice, and cost-effectiveness over the past 20 years. METHODS Eight implant registries were instituted with standardized collection from the electronic health record and other institutional data sources of patient characteristics, medical comorbidities, implant attributes, procedure details, surgical techniques, and outcomes (including complications, revisions, reoperations, hospital readmissions, and other utilization measures). A rigorous quality control system is in place to improve and maintain the quality of data. Data from the Implant Registries form the basis for multiple quality improvement and patient safety initiatives to minimize variation in care, promote clinical best practices, facilitate recalls, perform benchmarking, identify patients at risk, and construct reports about individual surgeons. RESULTS Following the inception of the Implant Registries, there was an observed (1) reduction in opioid utilization following orthopedic procedures, (2) reduction in use of bone morphogenic protein during lumbar fusion allowing for cost savings, (3) reduction in allograft for anterior cruciate ligament reconstruction and subsequent decrease in organizationwide revision rates, (4) cost savings through expansion of same-day discharge programs for joint arthroplasty, (5) increase in the use of cement fixation in the hemiarthroplasty treatment of hip fracture, and (6) organizationwide discontinuation of an endograft device associated with a higher risk for adverse outcomes following endovascular aortic aneurysm repair. CONCLUSION The use of Implant Registries within our health system, along with clinical leadership and organizational commitment to a learning health system, was associated with improved quality and safety outcomes and reduced costs. The exact mechanisms by which such registries affect health outcomes and costs require further study.
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Goree JH, Grant SA, Dickerson DM, Ilfeld BM, Eshraghi Y, Vaid S, Valimahomed AK, Shah JR, Smith GL, Finneran JJ, Shah NN, Guirguis MN, Eckmann MS, Antony AB, Ohlendorf BJ, Gupta M, Gilbert JE, Wongsarnpigoon A, Boggs JW. Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement. Neuromodulation 2024:S1094-7159(24)00064-3. [PMID: 38739062 DOI: 10.1016/j.neurom.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVES Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA. MATERIALS AND METHODS Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT). RESULTS A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing. CONCLUSIONS This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.
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Affiliation(s)
- Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Stuart A Grant
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Yashar Eshraghi
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Sandeep Vaid
- Better Health Clinical Research, Newnan, GA, USA
| | | | - Jarna R Shah
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - G Lawson Smith
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Nirav N Shah
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Maged N Guirguis
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Maxim S Eckmann
- Department of Anesthesiology, University of Texas San Antonio, San Antonio, TX, USA
| | | | - Brian J Ohlendorf
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Mayank Gupta
- Neuroscience Research Center, Overland Park, KS, USA
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Masood R, Mandalia K, Pagani NR, Moverman MA, Puzzitiello RN, Menendez ME, Salzler MJ. Functional somatic syndromes are associated with inferior outcomes and increased complications after hip and knee arthroplasty: a systematic review. ARTHROPLASTY 2024; 6:2. [PMID: 38173047 PMCID: PMC10765755 DOI: 10.1186/s42836-023-00223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Functional somatic syndromes (FSSs), defined as chronic physical symptoms with no identifiable organic cause, may impact results after hip and knee arthroplasty. The purpose of this study was to perform a systematic review assessing the relationship between FSSs and clinical outcomes after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). METHODS The PubMed and Web of Science databases were queried from January 1955 through December 2021 for studies investigating the impact of at least one FSS (fibromyalgia, irritable bowel syndrome (IBS), chronic headaches, and chronic low back pain) on outcomes after primary THA/TKA/UKA. Outcomes of interest included patient-reported outcome measures (PROMs), postoperative opioid use, complications, revisions, and costs of care. RESULTS There were twenty-eight studies, including 768,909 patients, of which 378,384 had an FSS. Five studies reported preoperative PROMs prior to THA/TKA, all of which showed worse PROMs among patients with at least 1 FSS diagnosis. Thirteen studies reported postoperative PROMs after THA/TKA, all of which demonstrated worse PROMs among patients with at least 1 FSS diagnosis. Patients with FSS diagnoses were more likely to continue using opioids at 3, 6, and 12 months following TKA, THA, and UKA. Medical and surgical complications, as well as revision rates, were higher among patients with FSSs. CONCLUSION Patients with FSSs have inferior PROMs and are at increased risk for prolonged postoperative opioid use, medical and surgical complications, and revision after hip and knee arthroplasty. Improved understanding of the factors influencing the success of hip and knee arthroplasty is critical. Future studies should address the biopsychosocial determinants of health that can impact outcomes after total joint arthroplasty.
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Affiliation(s)
- Raisa Masood
- Department of Orthopaedic Surgery, Tufts Medical Center, Biewand Building, 7th Floor, 800 Washington St., Box 306, Boston, MA, 02111, USA
| | | | - Nicholas R Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Biewand Building, 7th Floor, 800 Washington St., Box 306, Boston, MA, 02111, USA
| | - Michael A Moverman
- Department of Orthopaedic Surgery, Tufts Medical Center, Biewand Building, 7th Floor, 800 Washington St., Box 306, Boston, MA, 02111, USA
| | - Richard N Puzzitiello
- Department of Orthopaedic Surgery, Tufts Medical Center, Biewand Building, 7th Floor, 800 Washington St., Box 306, Boston, MA, 02111, USA
| | | | - Matthew J Salzler
- Department of Orthopaedic Surgery, Tufts Medical Center, Biewand Building, 7th Floor, 800 Washington St., Box 306, Boston, MA, 02111, USA.
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Fiedler B, Bieganowski T, Anil U, Lin CC, Habibi AA, Schwarzkopf R. Can pain be improved with retention of the posterior cruciate ligament during total knee arthroplasty? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3395-3401. [PMID: 37140671 DOI: 10.1007/s00590-023-03562-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/23/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE The purpose of the current study was to determine if differences exist between cruciate-retaining (CR) and posterior-stabilized (PS) implant articulations for total knee arthroplasty (TKA) with regards to early post-operative pain. METHODS We retrospectively reviewed patients who underwent primary TKA, with the same TKA implant design, at our institution between January 2018 and July 2021. Patients were stratified based on whether they received a CR or non-constrained PS (PSnC) articulation and propensity score matched in a 1:1 ratio. A sub-analysis matching patient who received a constrained PS implant (PSC) to those undergoing CR TKA and PSnC TKA was also carried out. Opioid dosages were converted to morphine milligram equivalents (MME). RESULTS 616 patients after CR TKA were matched 1:1 to 616 patients with a PSnC implant. There were no significant differences between demographic variables. There were no statistically significant differences in opioid usage measured by MME on post-operative day (POD) 0 (p = 0.171), POD1 (p = 0.839), POD2 (p = 0.307), or POD3 (p = 0.138); VAS pain scores (p = 0.175); or 90-day readmission rate for pain (p = 0.654). A sub-analysis of CR versus PSC TKA demonstrated no significant differences in opioid usage on POD0 (p = 0.765), POD1 (p = 0.747), POD2 (p = 0.564), POD3 (p = 0.309); VAS pain scores (p = 0.293); and 90-day readmission rate for pain (p > 0.9). CONCLUSION Our analysis demonstrated no significant difference in post-operative VAS pain scores and MME usage based on implant. The results suggest that neither the type of articulation or constraint used for primary TKA has a significant impact on immediate post-operative pain and opioid consumption. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Benjamin Fiedler
- Department of Orthopedic Surgery, NYU Langone Orthopedic Center, NYU Langone Health, 301 East 17th Street, 14th Floor, New York, NY, USA
| | - Thomas Bieganowski
- Department of Orthopedic Surgery, NYU Langone Orthopedic Center, NYU Langone Health, 301 East 17th Street, 14th Floor, New York, NY, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Orthopedic Center, NYU Langone Health, 301 East 17th Street, 14th Floor, New York, NY, USA
| | - Charles C Lin
- Department of Orthopedic Surgery, NYU Langone Orthopedic Center, NYU Langone Health, 301 East 17th Street, 14th Floor, New York, NY, USA
| | - Akram A Habibi
- Department of Orthopedic Surgery, NYU Langone Orthopedic Center, NYU Langone Health, 301 East 17th Street, 14th Floor, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopedic Center, NYU Langone Health, 301 East 17th Street, 14th Floor, New York, NY, USA.
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Christensen TH, Gemayel AC, Bieganowski T, Lawrence K, Rozell JC, Macaulay WB, Schwarzkopf R. Opioid Use during Hospitalization following Total Knee Arthroplasty: Trends in Consumption from 2016 to 2021. J Arthroplasty 2023; 38:S26-S31. [PMID: 37019314 DOI: 10.1016/j.arth.2023.03.074] [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: 11/29/2022] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION In response to physician and patient concerns, many institutions have adopted protocols aimed at reducing postoperative opioid consumption after total knee arthroplasty (TKA). Thus, this study sought to examine how consumption of opioids has changed following TKA in the past six years. METHODS We conducted a retrospective review of all 10,072 patients who received primary TKA at our institution from January 2016 to April 2021. We collected baseline demographic data including patient age, sex, race, body mass index (BMI), American Society of Anesthesiologist (ASA) classification, as well as dosage and type of opioid medication prescribed on each postoperative day while the patient was hospitalized following TKA. This data was converted to milligram morphine equivalents (MME) per day hospitalized to compare rates of opioid use over time. RESULTS Our analysis found the greatest daily opioid use was in 2016 (43.2±68.6 MME/day) and the least was in 2021 (15.0±29.2 MME/day). Linear regression analyses found a significant linear downward trend in postoperative opioid consumption over time, with a decrease of 5.55 MME per day per year (Adjusted R-squared: 0.982, P<0.001). The highest visual analog scale (VAS) score was 4.45 in 2016 and the lowest was 3.79 in 2021 (P<0.001). CONCLUSION Opioid reducing protocols have been implemented for patients recovering from primary TKA in an effort to decrease reliance on opioids for postoperative pain control. The results of this study demonstrate that such protocols have been successful in reducing overall opioid use during hospitalization following TKA.
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Affiliation(s)
| | - Anthony C Gemayel
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Thomas Bieganowski
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Kyle Lawrence
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - William B Macaulay
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York.
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Nozawa K, Lin Y, Ebata N, Wakabayashi R, Ushida T, Deie M, Kikuchi S. Perioperative Analgesics and Anesthesia as Risk Factors for Postoperative Chronic Opioid Use in Patients Undergoing Total Knee Arthroplasty: A Retrospective Cohort Study Using Japanese Hospital Claims Data. Drugs Real World Outcomes 2023:10.1007/s40801-023-00363-5. [PMID: 36976516 DOI: 10.1007/s40801-023-00363-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Patients with chronic postsurgical pain are commonly prescribed opioids chronically because of refractory pain although chronic opioid use can cause various severe problems. OBJECTIVE We aimed to investigate postoperative chronic opioid use and its association with perioperative pain management in patients who underwent a total knee arthroplasty in a Japanese real-world clinical setting. METHODS We conducted a retrospective cohort study using an administrative claims database. We used a multivariate logistic regression analysis to examine the association between perioperative analgesic and anesthesia prescriptions and postoperative chronic opioid use. We calculated all-cause medication and medical costs for each patient. RESULTS Of the 23,537,431 patient records, 14,325 patients met the criteria and were included in the analyses. There were 5.4% of patients with postoperative chronic opioid use. Perioperative prescriptions of weak opioids, strong and weak opioids, and the α2δ ligand were significantly associated with postoperative chronic opioid use (adjusted odds ratio [95% confidence interval], 7.22 [3.89, 13.41], 7.97 [5.07, 12.50], and 1.45 [1.13, 1.88], respectively). Perioperative combined prescriptions of general and local anesthesia were also significantly associated with postoperative chronic opioid use (3.37 [2.23, 5.08]). These medications and local anesthesia were more commonly prescribed on the day following surgery, after routinely used medications and general anesthesia were prescribed. The median total direct costs were approximately 1.3-fold higher among patients with postoperative chronic opioid use than those without postoperative chronic opioid use. CONCLUSIONS Patients who require supplementary prescription of analgesics for acute postsurgical pain are at high risk of postoperative chronic opioid use and these prescriptions should be given careful consideration to mitigate the patient burden.
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Affiliation(s)
- Kazutaka Nozawa
- Department of Public Health, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan.
- Medical Affairs, Pfizer Japan, Inc., Tokyo, Japan.
| | - Yingsong Lin
- Department of Public Health, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Nozomi Ebata
- Department of Public Health, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
- Medical Affairs, Pfizer Japan, Inc., Tokyo, Japan
| | | | - Takahiro Ushida
- Multidisciplinary Pain Center, Aichi Medical University, Nagakute, Aichi, Japan
| | - Masataka Deie
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Shogo Kikuchi
- Department of Public Health, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
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Lan YT, Pagani NR, Chen YW, Niu R, Chang DC, Talmo CT, Hollenbeck BL, Mattingly DA, Smith EL. A Safe Number of Perioperative Opioids to Reduce the Risk of New Persistent Usage Among Opioid-Naïve Patients Following Total Joint Arthroplasty. J Arthroplasty 2023; 38:18-23.e1. [PMID: 35987496 DOI: 10.1016/j.arth.2022.08.018] [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: 05/24/2022] [Revised: 08/07/2022] [Accepted: 08/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Higher initial opioid dosing increases the risk of prolonged opioid use following total joint arthroplasty (TJA), and the safe amounts to prescribe are unknown. We examined the relationship between perioperative opioid exposure and new persistent usage among opioid-naïve patients after total knee and hip arthroplasty. METHODS In this retrospective cohort study, 22,310 opioid-naïve patients undergoing primary TJA between 2018 and 2019 were identified within a commercial claims database. Perioperative opioid exposure was defined as total dose of opioid prescription in morphine milligram equivalents (MME) between 1 month prior to and 2 weeks after TJA. New persistent usage was defined as at least one opioid prescription between 90 and 180 days postoperatively. Multivariate regression analyses were performed to examine the relationship between the perioperative dosage group and the development of new persistent usage. RESULTS For the total patient cohort, 8.1% developed new persistent usage. Compared to patients who received <300 MME, patients who received 600-900 MME perioperatively had a 77% increased risk of developing new persistent usage (odds ratio 1.77, 95% CI, 1.44-2.17), and patients who received ≥1,200 MME perioperatively had a 285% increased risk (odds ratio 3.85, 95% CI, 3.13-4.74). CONCLUSION We found a dose-dependent association between perioperative MME and the risk of developing new persistent usage among opioid-naïve patients following TJA. We recommend prescribing <600 MME (equivalent to 80 pills of 5 mg oxycodone) during the perioperative period to reduce the risk of new persistent usage. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yu-Tung Lan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas R Pagani
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruijia Niu
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carl T Talmo
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Brian L Hollenbeck
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - David A Mattingly
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Eric L Smith
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
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Hunter CW, Deer TR, Jones MR, Chang Chien GC, D'Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, Sayed D, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2683-2745. [PMID: 36132996 PMCID: PMC9484571 DOI: 10.2147/jpr.s370469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.
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Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA.,Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Ryan S D'Souza
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Erica R Eldon
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lissa Hewan-Lowe
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jillian A Maloney
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Anthony J Mazzola
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jeanmarie Tari
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Chris Wie
- Interventional Spine and Pain, Dallas, TX, USA
| | - Douglas Beall
- Comprehensive Specialty Care, Oklahoma City, OK, USA
| | - Dawood Sayed
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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Kiani S, Poeran J, Zhong H, Wilson LA, Poultsides L, Liu J, Memtsoudis SG. Tramadol prescribed at discharge is associated with lower odds of chronic opioid use after elective total joint arthroplasty. Reg Anesth Pain Med 2022; 47:rapm-2022-103486. [PMID: 35760515 DOI: 10.1136/rapm-2022-103486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/12/2022] [Indexed: 12/16/2022]
Abstract
INTRODUCTION We aimed to study the association between tramadol prescribed at discharge (after elective total hip and knee arthroplasty (THA/TKA) surgery) and chronic opioid use postoperatively. METHODS This retrospective cohort study queried the Truven MarketScan database and identified patients who underwent an elective THA/TKA surgery between 2016 and 2018 and were prescribed opioids at discharge (n=81 049). Multivariable analysis was conducted to study the association between tramadol prescription at discharge and chronic opioid use, with additional analysis adjusting for the amount of opioids prescribed in oral morphine equivalents. Chronic opioid use was defined as filling ≥10 opioid prescriptions or prescriptions for ≥120 pills within the period from 90 days to 1 year after surgery. RESULTS Overall, tramadol was prescribed at discharge in 11.0% of all THA/TKA cases. Of those, 26.9% and 73.1% received tramadol only or tramadol with another opioid, respectively. Chronic opioid use was observed in 5.4% of cases. After adjustment for relevant covariates, prescription of tramadol combined with another opioid at discharge was associated with lower odds of chronic opioid use comparing to prescription of other opioids (OR 0.69 CI 0.61 to 0.78). DISCUSSION Among patients undergoing elective THA/TKA surgery and discharged with a prescription of opioids, we found that prescription of tramadol combined with another opioid was associated with lower odds of chronic opioid use. This finding must be considered in the context of the tramadol's pharmacology, as well-described genetic differences in metabolism that can make it ineffective in many patients, while for patients with ultrarapid metabolism can cause drug-drug interactions and adverse events, including feelings of high and seizures.
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Affiliation(s)
- Sara Kiani
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jashvant Poeran
- Departments of Orthopedics / Population Health Science & Policy / Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Lazaros Poultsides
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
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Kleeman-Forsthuber L, Pollet A, Johnson RM, Boyle J, Jennings JM, Dennis DA. Evaluation of Low-Dose Versus High-Dose Opioid Pathway in Opioid-Naïve Patients After Total Knee Arthroplasty. Arthroplast Today 2022; 14:81-85. [PMID: 35252511 PMCID: PMC8889259 DOI: 10.1016/j.artd.2021.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 11/16/2021] [Accepted: 11/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background Pain control after total knee arthroplasty (TKA) remains challenging. Tramadol is a weak opioid with potentially lower side effects and risk for dependency than stronger opioids. The purpose of this study was to evaluate efficacy and safety of tramadol after TKA in opioid-naïve patients compared with stronger opioids. Methods A retrospective review of patients who underwent primary TKA was performed. In September 2018, opioid-naïve patients were prescribed tramadol instead of oxycodone. Patients receiving tramadol (low-opioid group) were matched to patients discharged with oxycodone before this transition (high-opioid group). We compared morphine milligram equivalent (MME) consumption and outcomes up to 3 months postoperatively. Results Two-hundred and five patients underwent TKA, with 126 receiving tramadol. Fourteen patients were converted to stronger opioid (11.2% conversion rate). Seventy patients from the low-opioid group were matched to 70 patients in the high-opioid group. Average daily inpatient MME consumption was higher in the high-opioid group (40.0 ± 27.4 vs 16.3 ± 10.9, P = .000). Outpatient prescribed MME was significantly higher in the high-opioid group (135.5 ± 71.5 vs 75.3 ± 51.3, P = .000) along with a higher number of refills (0.53 ± 1.1 vs 0.886 ± 0.94, P = .041). Knee range of motion was not statistically different at any timepoint postoperatively. There was higher adverse event rate in the low-opioid group (8.6% vs 5.7%) but not statically significant. Conclusions Low opioid regimen following TKA showed lower MME consumption than high opioid regimen with no effect on outcomes up to 3 months. Use of low opioid regimen should be considered for TKA surgery.
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Affiliation(s)
- Lindsay Kleeman-Forsthuber
- Colorado Joint Replacement, Denver, CO, USA
- Corresponding author. Thomas W. Huebner Medical Office Building, 160 Allen Street, Rutland, VT 05701, USA. Tel.: + 1 8027752937.
| | | | | | | | - Jason M. Jennings
- Colorado Joint Replacement, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
| | - Douglas A. Dennis
- Colorado Joint Replacement, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
- Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
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Beck EC, Nwachukwu BU, Drager J, Jan K, Rasio J, Krishnamoorthy VP, Nho SJ. Prolonged Postoperative Opioid Use After Arthroscopic Femoroacetabular Impingement Syndrome Surgery: Predictors and Outcomes at Minimum 2-Year Follow-up. Orthop J Sports Med 2021; 9:23259671211038933. [PMID: 34888387 PMCID: PMC8649101 DOI: 10.1177/23259671211038933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/04/2021] [Indexed: 12/05/2022] Open
Abstract
Background: The association between prolonged postoperative opioid use on outcomes after hip preservation surgery is not known. Purpose: To compare minimum 2-year patient-reported outcomes (PROs) between patients who required ≥1 postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) versus patients who did not require a refill and to identify preoperative predictors for patients requiring ≥1 postoperative opioid refill. Study Design: Cohort study; Level of evidence, 3. Methods: Data from consecutive patients who underwent arthroscopic surgery for FAIS between January 2012 and January 2017 were analyzed. Multivariate regression analysis was performed to classify patient and radiographic variables as predictive of requiring ≥1 opioid prescription refill after surgery. Patients completed the following PROs preoperatively and at 2-year follow-up: Hip Outcome Score— Activities of Daily Living subscale (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-12), and 100-point visual analog scale (VAS) for pain and satisfaction. Scores were compared between patients needing additional prescription opioids and those who did not. Results: A total of 775 patients, of whom 141 (18.2%) required ≥1 opioid prescription refill, were included in the analysis. Patients requiring opioid refills had significantly lower 2-year postoperative PRO scores compared with patients not requiring refills: HOS-ADL (79.9 ± 20.3 vs 88.7 ± 14.9), HOS-SS (64.6 ± 29.5 vs 78.2 ± 23.7), mHHS (74.2 ± 21.1 vs 83.6 ± 15.9), iHOT-12 (63.6 ± 27.9 vs 74.9 ± 24.8), and VAS satisfaction (73.4 ± 30.3 vs 82.2 ± 24.9), as well as significantly more pain (26.8 ± 23.4 vs 17.9 ± 21.8) (P ≤ .001 for all). Predictors of requiring a postoperative opioid refill included patients with active preoperative opioid use (odds ratio, 3.12 [95% confidence interval, 1.06-9.21]; P = .039) and larger preoperative alpha angles (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .03). Conclusion: Patients requiring ≥1 opioid prescription refill after hip arthroscopy for FAIS had lower preoperative and 2-year PRO scores when compared with patients not requiring refills. Additionally, active opioid use at the time of surgery was found to be predictive of requiring additional opioids for pain management.
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Affiliation(s)
- Edward C Beck
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Benedict U Nwachukwu
- Division of Sports Medicine Surgery, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Justin Drager
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kyleen Jan
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jonathan Rasio
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Vignesh P Krishnamoorthy
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Malahias MA, Loucas R, Loucas M, Denti M, Sculco PK, Greenberg A. Preoperative Opioid Use Is Associated With Higher Revision Rates in Total Joint Arthroplasty: A Systematic Review. J Arthroplasty 2021; 36:3814-3821. [PMID: 34247870 DOI: 10.1016/j.arth.2021.06.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/06/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although preoperative opioid use has been associated with poor postoperative patient-reported outcome measures and delayed return to work in patients undergoing total joint arthroplasty, direct surgery-related complications in patients on chronic opioids are still not clear. Thus, we sought to perform a systematic review of the literature to evaluate the influence of preoperative opioid use on postoperative complications and revision following primary total joint arthroplasty. METHODS Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we queried PubMed, EMBASE, the Cochrane Library, and the ISI Web of Science for studies investigating the influence of preoperative opioid use on postoperative complications following total hip arthroplasty and total knee arthroplasty up to May 2020. RESULTS After applying exclusion criteria, 10 studies were included in the analysis which represented 87,165 opioid users (OU) and 5,214,010 nonopioid users (NOU). The overall revision rate in the OU group was 4.79% (3846 of 80,303 patients) compared to 1.21% in the NOU group (43,719 of 3,613,211 patients). There was a higher risk of aseptic loosening (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.11-1.53, P = .002), periprosthetic fractures (OR 1.89, 95% CI 1.53-2.34, P < .00001), and dislocations (OR 1.26, 95% CI 1.14-1.39, P < .00001) in the OU group compared to the NOU group. Overall, 5 of 6 studies reporting on periprosthetic joint infection (PJI) rates showed statistically significant correlation between preoperative opioid use and higher PJI rates. CONCLUSION There is strong evidence that preoperative opioid use is associated with a higher overall revision rate for aseptic loosening, periprosthetic fractures, and dislocation, and an increased risk for PJI. LEVEL OF EVIDENCE Level III, systematic review.
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Affiliation(s)
- Michael-Alexander Malahias
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY; Department of Orthopedics and Traumatology, Clinica Ars Medica, Gravesano, Ticino, Switzerland
| | - Rafael Loucas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marios Loucas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Matteo Denti
- Department of Orthopedics and Traumatology, Clinica Ars Medica, Gravesano, Ticino, Switzerland; Department of Orthopaedics, IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Peter K Sculco
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY
| | - Alexander Greenberg
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY; Hadassah Medical Center, Jerusalem, Israel
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Tay HP, Wang X, Narayan SW, Penm J, Patanwala AE. Persistent postoperative opioid use after total hip or knee arthroplasty: A systematic review and meta-analysis. Am J Health Syst Pharm 2021; 79:147-164. [PMID: 34537828 PMCID: PMC8513405 DOI: 10.1093/ajhp/zxab367] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To identify the proportion of patients with continued opioid use after total hip or knee arthroplasty. Methods This systematic review and meta-analysis searched Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts for articles published from January 1, 2009, to May 26, 2021. The search terms (opioid, postoperative, hospital discharge, total hip or knee arthroplasty, and treatment duration) were based on 5 key concepts. We included studies of adults who underwent total hip or knee arthroplasty, with at least 3 months postoperative follow-up. Results There were 30 studies included. Of these, 17 reported on outcomes of total hip arthroplasty and 19 reported on outcomes of total knee arthroplasty, with some reporting on outcomes of both procedures. In patients having total hip arthroplasty, rates of postoperative opioid use at various time points were as follows: at 3 months, 20% (95% CI, 13%-26%); at 6 months, 17% (95% CI, 12%-21%); at 9 months, 19% (95% CI, 13%-24%); and at 12 months, 16% (95% CI, 15%-16%). In patients who underwent total knee arthroplasty, rates of postoperative opioid use were as follows: at 3 months, 26% (95% CI, 19%-33%); at 6 months, 20% (95% CI, 17%-24%); at 9 months, 23% (95% CI, 17%-28%); and at 12 months, 21% (95% CI, 12%-29%). Opioid naïve patients were less likely to have continued postoperative opioid use than those who were opioid tolerant preoperatively. Conclusion Over 1 in 5 patients continued opioid use for longer than 3 months after total hip or knee arthroplasty. Clinicians should be aware of this trajectory of opioid consumption after surgery.
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Affiliation(s)
- Hui Ping Tay
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia
| | - Xinyi Wang
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia
| | - Sujita W Narayan
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia
| | - Jonathan Penm
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Asad E Patanwala
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, New South Wales, Australia.,Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Urban JA, Dolesh K, Martin E. A Multimodal Pain Management Protocol Including Preoperative Cryoneurolysis for Total Knee Arthroplasty to Reduce Pain, Opioid Consumption, and Length of Stay. Arthroplast Today 2021; 10:87-92. [PMID: 34286056 PMCID: PMC8280475 DOI: 10.1016/j.artd.2021.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 06/01/2021] [Accepted: 06/14/2021] [Indexed: 10/25/2022] Open
Abstract
Background A retrospective analysis was conducted to determine if cryoneurolysis of superficial genicular nerves combined with standard care decreased postoperative opioids and pain after total knee arthroplasty (TKA). Methods Data from patients who underwent TKA at a single center were analyzed. Patients who received standardized cryoneurolysis before TKA were compared with a historical control group including patients who underwent TKA without cryoneurolysis. Both groups received a similar perioperative multimodal pain management protocol. The primary outcome was opioid intake at various time points from hospital stay to 6 weeks after discharge. Additional outcomes included pain, length of stay, and range of motion. Results The analysis included 267 patients (cryoneurolysis group: n = 169; control group: n = 98). During the hospital stay, the cryoneurolysis group had 51% lower daily morphine milligram equivalents (MMEs) (47 vs 97 MMEs; ratio estimate, 0.49 [95% confidence interval (CI), 0.43-0.56]; P < .0001) and 22% lower mean pain score (ratio estimate, 0.78 [95% CI, 0.70-0.88]; P < .0001) vs the control group. The cryoneurolysis group received significantly fewer cumulative MMEs, including discharge prescriptions, than the control group at week 2 (855 vs 1312 MMEs; ratio estimate, 0.65 [95% CI, 0.59-0.73]; P < .0001) and week 6 (894 vs 1406 MMEs; ratio estimate, 0.64 [95% CI, 0.57-0.71]; P < .0001). The cryoneurolysis group had significant 44% reduction in overall length of stay (P < .0001) and greater flexion degree at discharge (P < .0001). Conclusions Addition of preoperative cryoneurolysis to a multimodal pain management protocol reduced opioids and in-hospital pain and optimized outcomes during the 6-week recovery period after TKA.
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15
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Terhune EB, Hannon CP, Burnett RA, Della Valle CJ. Daily Dose of Preoperative Opioid Prescriptions Affects Outcomes After Total Knee Arthroplasty. J Arthroplasty 2021; 36:2302-2306. [PMID: 33526394 DOI: 10.1016/j.arth.2021.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/24/2020] [Accepted: 01/07/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The use of preoperative opioids is associated with complications after total knee arthroplasty (TKA), but the dosing threshold that constitutes this risk is not known. The purpose of this study was to identify the preoperative daily opioid dose associated with increased complications after primary TKA. METHODS Patients who underwent primary TKA in the Humana claims database (2007-2016) with an opioid prescription within 3 months before surgery were identified. All opioids prescribed within 3 months before TKA were converted to milligram morphine equivalents. Patients were stratified based on daily opioid dose: tier 1) <10, tier 2) 10-25, tier 3) 25-50, tier 4) >50 milligram morphine equivalents. Patients were matched to opioid-naïve patients by comorbidities, age, and gender. Emergency department (ED) visits, readmissions, and surgical complications were compared. RESULTS A total of 20,019 patients using preoperative opioids were identified and matched. ED visits and readmissions within 90 days were significantly higher in opioid users in all tiers (relative risk (RR) of ED visit: 1.25, 1.28, 1.34, and 1.25, respectively; readmission: 1.13, 1.17, 1.22, and 1.19, respectively). Rates of prosthetic joint infection were increased in opioid users in tiers 2, 3, and 4, and the risk increased in a dose-dependent manner (RR 1.37, 1.39, and 1.50, respectively). Patients in tier 4 had an increased risk of revision surgery (RR 1.44) at 2 years. CONCLUSION Preoperative opioid use is associated with a dose-dependent increase in postoperative complications after TKA. Just two 5mg hydrocodone tablets daily lead to increased ED visits and readmission. Higher doses are associated with an increased risk of prosthetic joint infection and revision surgery.
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Affiliation(s)
- E Bailey Terhune
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | | | - Robert A Burnett
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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Comparison of opioid prescribing upon hospital discharge in patients receiving tapentadol versus oxycodone following orthopaedic surgery. Int J Clin Pharm 2021; 43:1602-1608. [PMID: 34089144 DOI: 10.1007/s11096-021-01290-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
Background The changing of opioids during the transition of care from hospital to home may be associated with harm. Objective To compare patients receiving tapentadol IR versus oxycodone IR following orthopaedic surgery during hospitalisation with regard to the changing of opioids at hospital discharge. Setting A major metropolitan tertiary referral hospital in Australia. Methods This is a retrospective cohort study. Participants included adult orthopaedic surgery patients receiving postoperative tapentadol IR or oxycodone IR during hospitalisation between 1 January 2018 and 30 June 2019. Main outcome measure The proportion of patients for whom the opioid prescribed was changed at hospital discharge. Results The study cohort included 199 patients. Of these, 100 patients received oxycodone and 99 patients received tapentadol post-operatively during hospitalisation. The mean age was 66 years (SD, 12 years) and 111 (56%) were female. The most common surgeries were total knee arthroplasty (91, 46%), total hip arthroplasty (63, 32%) and shoulder surgery (26, 13%). Patients in the tapentadol group were more likely to be changed to a different opioid upon hospital discharge than the oxycodone group (57% versus 9%, difference 48% [95% CI 36-59%, p < 0.01). After adjusting for confounders, post-operative tapentadol use was more likely to be associated with opioid changing upon discharge (OR 16.5, 95% CI 6.7 to 40.8, p < 0.01). Conclusions The post-operative use of tapentadol IR during hospitalisation was associated with an increased likelihood of opioid changing at hospital discharge. This practice could have patient safety implications.
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Hanley AW, Gililland J, Erickson J, Pelt C, Peters C, Rojas J, Garland EL. Brief preoperative mind-body therapies for total joint arthroplasty patients: a randomized controlled trial. Pain 2021; 162:1749-1757. [PMID: 33449510 PMCID: PMC8119303 DOI: 10.1097/j.pain.0000000000002195] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/08/2020] [Indexed: 12/16/2022]
Abstract
ABSTRACT Although knee and hip replacements are intended to relieve pain and improve function, up to 44% of knee replacement patients and 27% of hip replacement patients report persistent postoperative joint pain. Improving surgical pain management is essential. We conducted a single-site, 3-arm, parallel-group randomized clinical trial conducted at an orthopedic clinic, among patients undergoing total joint arthroplasty (TJA) of the hip or knee. Mindfulness meditation (MM), hypnotic suggestion (HS), and cognitive-behavioral pain psychoeducation (cognitive-behavioral pain psychoeducation) were each delivered in a single, 15-minute group session as part of a 2-hour, preoperative education program. Preoperative outcomes-pain intensity, pain unpleasantness, pain medication desire, and anxiety-were measured with numeric rating scales. Postoperative physical functioning at 6-week follow-up was assessed with the Patient-Reported Outcomes Measurement Information System Physical Function computer adaptive test. Total joint arthroplasty patients were randomized to preoperative MM, HS, or cognitive-behavioral pain psychoeducation (n = 285). Mindfulness meditation and HS led to significantly less preoperative pain intensity, pain unpleasantness, and anxiety. Mindfulness meditation also decreased preoperative pain medication desire relative to cognitive-behavioral pain psychoeducation and increased postoperative physical functioning at 6-week follow-up relative to HS and cognitive-behavioral pain psychoeducation. Moderation analysis revealed the surgery type did not differentially impact the 3 interventions. Thus, a single session of a simple, scripted MM intervention may be able to immediately decrease TJA patients' preoperative clinical symptomology and improve postoperative physical function. As such, embedding brief MM interventions in surgical care pathways has the potential to improve surgical outcomes for the millions of patients receiving TJA each year.
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Affiliation(s)
- Adam W. Hanley
- Center on Mindfulness and Integrative Health Intervention Development (C-MIIND), University of Utah
- College of Social Work, University of Utah
| | - Jeremy Gililland
- University of Utah Department of Orthopaedic Surgery
- Salt Lake City Veterans Affairs Medical Center
| | - Jill Erickson
- University of Utah Department of Orthopaedic Surgery
| | | | | | - Jamie Rojas
- Center on Mindfulness and Integrative Health Intervention Development (C-MIIND), University of Utah
- College of Social Work, University of Utah
| | - Eric L. Garland
- Center on Mindfulness and Integrative Health Intervention Development (C-MIIND), University of Utah
- College of Social Work, University of Utah
- Salt Lake City Veterans Affairs Medical Center
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Singh A, Chan PH, Prentice HA, Rao AG. Postoperative opioid utilization associated with revision risk following primary shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:1034-1041. [PMID: 32871267 DOI: 10.1016/j.jse.2020.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/05/2020] [Accepted: 08/10/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION With a substantial increase in utilization of primary shoulder arthroplasty, it is important to understand risk factors that may signal early failure and need for revision. Recent studies have reported that sustained postoperative opioid use is associated with a higher revision risk after total hip or knee arthroplasty. In this study, we evaluated postoperative opioid utilization as a risk factor for revision after primary shoulder arthroplasty. METHODS We conducted a cohort study using data from a United States integrated health care system's Shoulder Arthroplasty Registry. Patients who had a primary elective shoulder arthroplasty were identified (2009-2017); those with cancer or who underwent other arthroplasty procedures (either shoulder, hip, or knee) within the preceding year were excluded. Cumulative daily opioid utilization during the first year postoperative, calculated as oral morphine equivalents (OME), was categorized into 3 exposure groups: high user (≥15 mg OME daily), moderate user (<15 mg OME daily), and no opioid use (reference group). The exposure window was stratified into 2 time periods: postoperative days 1-90 and postoperative days 91-360. Multivariable Cox proportional-hazards regression was used to evaluate the association between postoperative opioid use and aseptic revision risk. RESULTS The final study sample included 8325 shoulder arthroplasty procedures. Of these individuals, 3707 (45%) received some opioid within the 1 year before the index procedure. We failed to observe a difference in aseptic revision risk between opioid utilization in the first 90 days postoperatively, regardless of dose. After the first 90 days, a higher revision risk was observed for high opioid users compared with nonusers (hazard ratio = 1.62, 95% confidence interval = 1.10-2.41), and no association was observed for moderate users (hazard ratio = 1.25, 95% confidence interval = 0.82-1.91). CONCLUSIONS We found a positive association between opioid consumption and aseptic revision risk after primary shoulder arthroplasty. This study cannot determine if opioids have a direct physiological cause that increases the risk of revision; rather it is likely that opioid consumption is a marker of chronic pain, poor function, and/or poor coping mechanisms. Further study is needed to determine if programs designed to decrease opioid use may impact revision risk after shoulder arthroplasty.
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Affiliation(s)
- Anshuman Singh
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, CA, USA.
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | | | - Anita G Rao
- Department of Orthopaedics, Northwest Permanente Medical Group, Portland, OR, USA
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Cheng X, Wang Z, Zhang Y, Zhang X. Oral administration of prednisone effectively reduces subacute pain after total knee arthroplasty. Orthop Traumatol Surg Res 2021; 107:102770. [PMID: 33333285 DOI: 10.1016/j.otsr.2020.102770] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 05/25/2020] [Accepted: 06/09/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Controlling the pain after TKA has always been our research focus. Dexamethasone has a significant effect in controlling acute pain following TKA. We hypothesis oral administration of prednisone could alleviate post-TKA subacute pain. METHODS This was a prospective, randomized controlled trial dividing patients into prednisone group and control group. Routine analgesic regimens included injection of cocktail mixture intraoperatively, oral celecoxib and tramadol postoperatively. Patients in prednisone group received oral administration of prednisone (10mg, qd, from the first day postoperatively, for 2 weeks). VAS was applied for evaluating pain with ambulation (PWA) and pain at rest (PAR). Follow-up was performed for about three months. The primary end-points were PWA and PAR; secondary end-points were postoperative daily celecoxib use and tramadol use. RESULTS A total of 49 patients were enrolled in prednisone group and control group, respectively. VAS of PWA was lower in prednisone group on the 7th, 14th and 28th (p=0.05) day after TKA than that in the control group. Meanwhile, VAS of PAR was lower in prednisone group on the postoperative 14th and 28th day (p=0.05) than that in the control group. CONCLUSIONS Continuous oral administration of 10mg prednisone for 14 days after TKA effectively alleviates subacute pain (including PWA and PAR) and reduces postoperative consumption of analgesics. LEVEL OF EVIDENCE II; low power randomized trial.
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Affiliation(s)
- Xingwang Cheng
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Street, 400037, Shapingba District, Chongqing, China
| | - Zhibing Wang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Street, 400037, Shapingba District, Chongqing, China
| | - Yuan Zhang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Street, 400037, Shapingba District, Chongqing, China
| | - Xia Zhang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Street, 400037, Shapingba District, Chongqing, China.
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Mihalko WM, Kerkhof AL, Ford MC, Crockarell JR, Harkess JW, Guyton JL. Cryoneurolysis before Total Knee Arthroplasty in Patients With Severe Osteoarthritis for Reduction of Postoperative Pain and Opioid Use in a Single-Center Randomized Controlled Trial. J Arthroplasty 2021; 36:1590-1598. [PMID: 33279353 DOI: 10.1016/j.arth.2020.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We hypothesized that preoperative cryoneurolysis of the superficial genicular nerves in patients with osteoarthritis would decrease postoperative opioid use relative to standard of care (SOC) treatment in patients undergoing total knee arthroplasty (TKA). METHODS Patients received either cryoneurolysis (intent-to-treat [ITT]: n = 62) or SOC (ITT: n = 62). The cryoneurolysis group received cryoneurolysis of the superficial genicular nerves 3-7 days before surgery plus a similar preoperative, intraoperative, and postoperative pain management protocol as the SOC group. The primary end point was cumulative opioid consumption in total daily morphine equivalents from discharge to the 6-week study follow-up assessment. Secondary end points included changes in pain and functional scores. Primary and secondary end points were assessed using ITT and per-protocol (PP) analyses. RESULTS The primary end point was not met in the ITT analysis (4.8 [cryoneurolysis] vs 6.1 [SOC] mg; P = .0841) but was met in the PP analysis (4.2 vs 5.9 mg; P = .0186) after excluding patients with medication deviations or missing follow-up data. Compared with the SOC group, the cryoneurolysis group had improved functional scores and numerical improvements in pain scores across all follow-up assessments, with significant improvements observed in current pain from baseline to the 72-hour and 2-week follow-up assessments and pain in the past week from baseline to the 12-week follow-up assessment. CONCLUSION Findings from the PP analysis suggest that preoperative cryoneurolysis in patients with knee osteoarthritis can reduce opioid consumption and improve functional outcomes after TKA.
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Affiliation(s)
- William M Mihalko
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - Anita L Kerkhof
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - Marcus C Ford
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - John R Crockarell
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - James W Harkess
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - James L Guyton
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
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21
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Preoperative Opioid Use Increases the Cost of Care in Total Joint Arthroplasty. J Am Acad Orthop Surg 2021; 29:310-316. [PMID: 32925386 DOI: 10.5435/jaaos-d-20-00316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/09/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Predictors of financial costs related to total joint arthroplasty (TJA) have become increasingly important becuase payment methods have shifted from fee for service to bundled payments. The purpose of this study was to assess the relationship between preoperative opioid use and cost of care in primary TJA. METHODS A retrospective study was conducted in Medicare patients who underwent elective unilateral primary total knee or hip arthroplasty between 2015 and 2018. Preoperative opioid usage, comorbidities, length of stay, and demographic information were obtained from chart review. The total episode-of-care (EOC) cost data was obtained from the Centers of Medicare and Medicaid Services based on Bundled Payments for Care Improvement Initiative Model 2, including index hospital and 90-day postacute care costs. Patients were grouped based on preoperative opioid usage. Costs were compared between groups, and multivariate linear regression analyses were performed to analyze whether preoperative opioid usage influenced the cost of TJA care. Analyses were risk-adjusted for patient risk factors, including comorbidities and demographics. RESULTS A total of 3,211 patients were included in the study. Of the 3,211 TJAs, 569 of 3,211 patients (17.7%) used preoperative opioids, of which 242 (42.5%) only used tramadol. EOC costs were significantly higher for opioid and tramadol users than nonopioid users ($19,229 versus $19,403 versus $17,572, P < 0.001). Multivariate regression predicted that the use of preoperative opioids in TJA was associated with increased EOC costs by $789 for opioid users (95% confidence interval [CI] $559 to $1,019, P < 0.001) and $430 for tramadol users (95% CI $167 to $694, P = 0.001). Total postacute care costs were also increased by 70% for opioid users (95% CI 44% to 102%, P < 0.001) and 48% for tramadol users (95% CI 22% to 80%, P < 0.001). DISCUSSION This study demonstrated that preoperative opioid usage was associated with higher cost of care in TJA. Limiting preoperative opioid use for pain management before TJA could contribute to cost savings within a bundled model.
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Derefinko KJ, Gong Z, Bursac Z, Hand SB, Johnson KC, Mihalko WM. Opioid Use Patterns After Primary Total Knee Replacement. Orthop Clin North Am 2021; 52:103-110. [PMID: 33752831 DOI: 10.1016/j.ocl.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Orthopedic surgeries are associated with the prescription of more narcotics than any other surgical specialty, particularly for total knee replacement (TKR) surgery. The authors examined controlled substance prescriptions following TKR surgery in a sample of 560 TKR patients. Results indicated that of all the 5164 prescriptions documented on the controlled substance monitoring database, 64% were for opioid medications. More than half of the patients received controlled substances from both the surgery site provider and a nonsurgery site provider in the year following surgery. The authors recommend that providers consider the possibility of outside prescribing when prescribing opioid analgesic.
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Affiliation(s)
- Karen J Derefinko
- Department of Preventive Medicine, Department of Pharmacology, Addiction Science, and Toxicology, The University of Tennessee Health Science Center, 66 North Pauline Street, Room 649, Memphis, TN 38163-2181, USA.
| | - Zhenghua Gong
- Department of Biostatistics, Florida International University, 11200 Southwest 8th Street, Miami, FL 33199, USA
| | - Zoran Bursac
- Department of Biostatistics, Florida International University, 11200 Southwest 8th Street, Miami, FL 33199, USA
| | - Sarah B Hand
- Department of Preventive Medicine, University of Tennessee Health Science Center, 403 Doctor's Office Building, 66 North Pauline Street, Memphis, TN 38163, USA. https://twitter.com/SarahHand
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, 659 Doctor's Office Building, 66 North Pauline Street, Memphis, TN 38163, USA
| | - William M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, Joint Graduate Program in Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, E226 Coleman Building, 956 Court Avenue, Memphis, TN 38163, USA
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23
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Triantafyllopoulos GK, Fiasconaro M, Wilson LA, Liu J, Poeran J, Memtsoudis SG, Poultsides LA. Bilateral Total Knee Arthroplasty and In-Hospital Opioid Dispension: A Population-Based Study. J Arthroplasty 2020; 35:3581-3586. [PMID: 32665155 DOI: 10.1016/j.arth.2020.06.041] [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: 01/20/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is paucity of data regarding opioid dispension in patients undergoing bilateral total knee arthroplasty (BTKA). Our aim is to compare in-hospital opioid dispension between BTKA and unilateral TKA (UTKA) and to identify other factors associated with opioid dispension in the BTKA and UTKA cohorts. METHODS Patients receiving elective TKA from 2006 to 2016 were retrospectively extracted from the Premier Healthcare Database. The effect of interest was bilateral TKA. Our primary outcome was in-hospital opioid dispension in oral morphine equivalents. Univariable statistics between study variables and TKA type were obtained. A multilevel logistic regression model was run for the outcome of high opioid dispension. RESULTS A total of 1,029,120 patients were included. Among these, 14,469 (1.4%) underwent a BTKA. Within the 10-year period studied, there was a decrease in opioid dispension in both groups. Logistic regression analysis showed that patients treated with BTKA had 1.68 times higher odds for high opioid dispension compared to UTKA patients (odds ratio = 1.68; 95.5% confidence interval = 1.62, 1.75; P < .0001). White race, longer length of stay, Charlson/Deyo index, type of insurance, rural location, general anesthesia, peripheral nerve block use, and patient-controlled analgesia were also associated with high opioid dispension. Conversely, a more recent year of surgery, female gender, older age, and administration of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors were associated with lower odds for high opioid dispension. CONCLUSION BTKA patients have increased odds for higher in-hospital opioid dispension compared to UTKA recipients. Utilization and prescribing habits should be examined to determine the optimal approach to opioid prescription in BTKA patients compared to UTKA.
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Affiliation(s)
- Georgios K Triantafyllopoulos
- Department of Orthopaedic Surgery, Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Megan Fiasconaro
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Jashvant Poeran
- Departments of Orthopedics and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Lazaros A Poultsides
- Academic Orthopaedic Department, Papageorgiou General Hospital, Aristotle University Medical School, Thessaloniki, Greece; Centre of Orthopaedics and Regenerative Medicine (C.O.RE.), Centre of Interdisciplinary Research and Innovation (C.I.R.I.), Aristotle University, Thessaloniki, Greece
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One-day Acceptance and Commitment Therapy workshop for preventing persistent post-surgical pain and dysfunction in at-risk veterans: A randomized controlled trial protocol. J Psychosom Res 2020; 138:110250. [PMID: 32961500 PMCID: PMC7554120 DOI: 10.1016/j.jpsychores.2020.110250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/07/2020] [Accepted: 09/13/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Persistent post-surgical pain is common among patients undergoing surgery, is detrimental to patients' quality of life, and can precipitate long-term opioid use. The purpose of this randomized controlled trial is to assess the effects of a behavioral intervention offered prior to surgery for patients at risk for poor post-surgical outcomes, including persistent pain and impaired functioning. METHODS Described herein is an ongoing randomized, patient- and assessor-blind, attention-controlled multisite clinical trial. Four hundred and thirty Veterans indicated for total knee arthroplasty (TKA) with distress and/or pain will be recruited for this study. Participants will be randomly assigned to a one-day (~5 h) Acceptance and Commitment Therapy workshop or one-day education and attention control workshop. Approximately two weeks following their TKA surgery, patients receive an individualized booster session via phone. Following their TKA, patients complete assessments at 1 week, 6 weeks, 3 months, and 6 months. RESULTS The primary outcomes are pain intensity and knee-specific functioning; secondary outcomes are symptoms of distress and coping skills. Mediation analyses will examine whether changes in symptoms of distress and coping skills have an impact on pain and functioning at 6 months in Veterans receiving ACT. This study is conducted mostly with older Veterans; therefore, results may not generalize to women and younger adults who are underrepresented in this veteran population. CONCLUSIONS The results of this study will provide the first evidence from a large-scale, patient- and assessor-blind controlled trial on the effectiveness of a brief behavioral intervention for the prevention of persistent post-surgical pain and dysfunction.
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Niazi F, Ong KL, Kidd VD, Lau E, Kurtz SM, Dysart SH, Malanga G. Decrease in opioid and intra-articular corticosteroid burden after intra-articular hyaluronic acid for knee osteoarthritis treatment. Pain Manag 2020; 10:387-397. [DOI: 10.2217/pmt-2020-0057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Aim: We studied changes in opioid prescriptions and corticosteroid injection use for knee osteoarthritis patients before and after intra-articular hyaluronic acid (HA) use and opioid prescriptions before and after knee arthroplasty (KA). Materials & methods: A total of 1,017,578 knee osteoarthritis members were ascertained from a commercial claims database (Health Intelligence Company LLC, IL, USA) using ICD9/ICD10 diagnosis codes. Results: Eighty two percent of HA patients did not fill opioid prescriptions postinjection, with 54% of opioid users discontinuing fills. Two-thirds of KA patients filled opioid prescriptions within 6 months postsurgery, with 78% of opioid users continuing fills and 62% of nonusers initiating use. Conclusion: Alternative therapies, such as HA, that reduce opioid use may alleviate opioid addiction risks for KA patients who use opioids in the pre- and postoperative periods.
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Affiliation(s)
- Faizan Niazi
- Ferring Pharmaceuticals, Inc., 100 Interpace Parkway, Parsippany, NJ 07054, USA
| | - Kevin L Ong
- Exponent, Inc., 3440 Market St, Suite 600, Philadelphia, PA 19104, USA
| | - Vasco Deon Kidd
- Department of Orthopaedic Surgery, University of California Irvine (UCI Health), 101 The City Drive South, Orange, CA 92868, USA
| | - Edmund Lau
- Exponent, Inc., 149 Commonwealth Ave, Menlo Park, CA 94025, USA
| | - Steven M Kurtz
- Exponent, Inc., 3440 Market St, Suite 600, Philadelphia, PA 19104, USA
| | - Stanley H Dysart
- Pinnacle Orthopaedics & Sports Medicine Specialists, 652 Church Street, Marietta, GA 30060, USA
| | - Gerard Malanga
- New Jersey Regenerative Institute, 197 Ridgedale Ave #210, Cedar Knolls, NJ 07927, USA; Clinical Professor Dept. of Physical Medicine & Rehabilitation, Rutgers School of Medicine – NJ Medical School Newark, NJ 07109, USA
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Namiranian K, Siglin J, Sorkin JD. The incidence of persistent postoperative opioid use among U.S. veterans: A national study to identify risk factors. J Clin Anesth 2020; 68:110079. [PMID: 33010491 DOI: 10.1016/j.jclinane.2020.110079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/23/2020] [Accepted: 09/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To calculate the incidence and identify the predictors of persistent postoperative opioid use at different postoperative days. BACKGROUND DATA A subset of surgical patients continues to use long-term opioids. The importance of the risk factors at different postoperative days is not known. DESIGN A historical cohort. SETTING Postoperative period. PATIENTS Opioid-naive U.S. veterans. INTERVENTIONS The surgical group had any one of 19 common invasive procedures. The control group is a 10% random sample. Each control was randomly assigned a surgery date. MEASUREMENTS The outcomes were the presence of persistent opioid use as determined by continued filling of prescriptions for opioids on postoperative days 90, 180, 270, and 365. MAIN RESULTS A total of 183,430 distinct surgical cases and 1,318,894 controls were identified. 1.0% of the surgical patients were using opioids at 90 days, 0.6% at 180 days, 0.4% at 270 days, and 0.1% at 365 days after the surgery. Surgery was strongly associated with postoperative persistent opioid use at day 90 (OR 3.67, 95% CI, 3.43-3.94, p < 0.001), at day 180 (OR 2.85, 2.67-3.12, p < 0.001), at day 270 (OR 2.63, 2.38-2.91, p < 0.001) and at day 365 (OR 2.11, 1.77-2.51, p < 0.001) compared to non-surgical controls. In risk factor analysis, being male and single were associated with persistent opioid use at earlier time points (90 and 180 days), while hepatitis C and preoperative benzodiazepine use were associated with persistent opioid use at later time points (270 and 365 days). CONCLUSIONS Many surgeries or invasive procedures are associated with an increased risk of persistent postoperative opioid use. The postoperative period is dynamic and the risk factors change with time.
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Affiliation(s)
- Khodadad Namiranian
- VA Maryland Health Care System, Baltimore, MD, United States of America; Department of Anesthesiology, University of Maryland, Baltimore, MD, United States of America; VA Central California Health Care System, Fresno, CA, United States of America.
| | - Jonathan Siglin
- School of Medicine, University of Maryland, Baltimore, MD, United States of America
| | - John David Sorkin
- VA Maryland Health Care System, Baltimore, MD, United States of America; Baltimore VA Medical Center Geriatric Research, Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States of America; Division of Gerontology and Geriatric Medicine, University of Maryland, Baltimore, MD, United States of America
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Dattilo JR, Cororaton AD, Gargiulo JM, McDonald JF, Ho H, Hamilton WG. Narcotic Consumption in Opioid-Naïve Patients Undergoing Total Hip and Knee Arthroplasty. J Arthroplasty 2020; 35:2392-2396. [PMID: 32451281 DOI: 10.1016/j.arth.2020.04.089] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/23/2020] [Accepted: 04/26/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with increased risk of prolonged narcotic requirement compared to total hip arthroplasty (THA). This study aims to compare acute postoperative narcotic consumption between the 2 procedures and quantify amount of narcotics used by opioid prescribed. METHODS From October 2017 to August 2019, patients were surveyed at 4-week follow-up to determine amount and duration of opioids used and whether they continued to require narcotics. Among 1332 patients who self-identified as opioid naïve, 670 underwent THA and 662 underwent TKA. Descriptive analysis was performed based on data type. RESULTS The total morphine equivalent dose (MED) used in the postoperative period was lower in THA than in TKA (143 ± 160 vs 259 ± 250 MED, P < .001). The duration of use was shorter, total amount of pills consumed was lower, and refill rates were less in THA compared to TKA regardless of which opioid was prescribed. A smaller proportion of patients required narcotics at 4-week follow-up in THA compared to TKA. A postoperative prescription of 45 pills of any one type of narcotic was sufficient for nearly 90% of THA patients, and 60 pills of any one type of narcotic was appropriate for over 75% of TKA patients. CONCLUSION THA is associated with less total narcotic consumption, shorter duration of use, less refills, and lower likelihood of requiring narcotics at 4-week follow-up. Percentiles of total narcotics consumed are provided to promote judicious postoperative prescribing patterns, and one could consider further reducing narcotics when utilizing our protocol, particularly for THA patients. LEVEL OF EVIDENCE This is a level III retrospective cohort study reviewing narcotic use in over 900 consecutive opioid-naïve patients undergoing total hip and knee arthroplasty.
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Affiliation(s)
| | | | | | | | - Henry Ho
- Anderson Orthopaedic Research Institute, Alexandria, VA
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Buys MJ, Bayless K, Romesser J, Anderson Z, Patel S, Zhang C, Presson AP, Brooke BS. Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service. Reg Anesth Pain Med 2020; 45:847-852. [PMID: 32848086 DOI: 10.1136/rapm-2020-101797] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/20/2020] [Accepted: 07/25/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic postsurgical pain and opioid use is a problem among patients undergoing many types of surgical procedures. A multidisciplinary approach to perioperative pain management known as a transitional pain service (TPS) may lower these risks. METHODS This retrospective cohort study was conducted at the Salt Lake City VA Medical Center to compare patients undergoing elective primary or revision total knee, hip, or shoulder replacement or rotator cuff repair in the year before (2017) and after (2018) implementation of a TPS. The primary outcome is the proportion of patients taking opioids 90 days after surgery. Secondary outcomes include new chronic opioid use (COU) after surgery as well as the proportion of previous chronic opioid users who stopped or decreased opioid use after surgery. RESULTS At 90 days after surgery, patients enrolled in TPS were significantly less likely to be taking opioids (13.4% TPS vs 27.3% pre-TPS; p=0.002). This relationship remained statistically significant in a multivariable logistic regression analysis, where the TPS group had 69% lower odds of postoperative COU compared with the preintervention group (OR: 0.31; 95% CI: 0.14 to 0.66; p=0.03). Opioid-naive patients enrolled in TPS were less likely to have new COU after surgery (0.7% TPS vs 8.4% pre-TPS; p=0.004). Further, patients enrolled in TPS with existing COU prior to surgery were more likely to reduce or completely stop opioid use after surgery (67.5% TPS vs 45.3% pre-TPS; p=0.037) as compared with pre-TPS. CONCLUSIONS These data suggest that a TPS is an effective strategy for preventing new COU and reducing overall opioid use following orthopedic joint procedures in a Veterans Affairs hospital.
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Affiliation(s)
- Michael J Buys
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA .,Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Kimberlee Bayless
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Jennifer Romesser
- Psychology, VA Salt Lake City Health Care System Mental Health Services, Salt Lake City, Utah, USA
| | - Zachary Anderson
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Shardool Patel
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Chong Zhang
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Angela P Presson
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Benjamin S Brooke
- Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Surgery, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
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Bernstein J, Feng J, Mahure S, Schwarzkopf R, Long WJ. Revision Total Knee Arthroplasty Is Associated With Significantly Higher Opioid Consumption as Compared With Primary Total Knee Arthroplasty in the Acute Postoperative Period. Arthroplast Today 2020; 6:172-175. [PMID: 32420435 PMCID: PMC7218159 DOI: 10.1016/j.artd.2020.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/18/2020] [Accepted: 04/02/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND There is a scarcity of studies investigating narcotic use after revision total knee arthroplasty (TKA). We compared immediate postsurgical narcotic consumption after revision TKA and primary TKA. METHODS A single-institution database was used to identify patients who underwent revision TKA or primary TKA between 2016 and 2019. Morphine milligram equivalents (MMEs) were calculated to discern narcotic usage, and pain visual analog score was also used. RESULTS A total of 7342 cases were identified: 88.65% primary TKA and 11.35% revision TKA. Opioid consumption for the first 24 hours postoperatively was significantly higher for the revision TKA group (133.1 MMEs vs 56.14 MMEs, P < .0001), as well as for the 24- to 48-hour time period. The visual analog pain scores were also higher for the revision TKA group. CONCLUSION The revision TKA group had a higher opioid requirement, most significant during the first 24 hours postoperatively, and expressed more pain in the acute postoperative period.
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Affiliation(s)
- Jenna Bernstein
- NYU Langone, Department of Orthopedics – Division of Adult Joint Reconstruction, New York, NY, USA
| | - James Feng
- NYU Langone, Department of Orthopedics – Division of Adult Joint Reconstruction, New York, NY, USA
| | - Siddharth Mahure
- NYU Langone, Department of Orthopedics – Division of Adult Joint Reconstruction, New York, NY, USA
| | - Ran Schwarzkopf
- NYU Langone, Department of Orthopedics – Division of Adult Joint Reconstruction, New York, NY, USA
| | - William J. Long
- NYU Langone, Department of Orthopedics – Division of Adult Joint Reconstruction, New York, NY, USA
- Insall-Scott-Kelly Institute, New York, NY, USA
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Hinman AD, Chan PH, Prentice HA, Paxton EW, Okike KM, Navarro RA. The Association of Race/Ethnicity and Total Knee Arthroplasty Outcomes in a Universally Insured Population. J Arthroplasty 2020; 35:1474-1479. [PMID: 32146110 DOI: 10.1016/j.arth.2020.02.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prior studies have documented racial/ethnic disparities in the United States for total knee arthroplasty (TKA) outcomes. One factor cited as a potential mediator is unequal access to care. We sought to assess whether racial/ethnic disparities persist in a universally insured TKA population. METHODS A US integrated health system's total joint replacement registry was used to identify elective primary TKA (2000-2016). Racial/ethnic differences in revision and 90-day postoperative events (readmission, emergency department [ED] visit, infection, venous thromboembolism, and mortality) were analyzed using Cox proportional hazard and logistic regression with adjustment for confounders. RESULTS Of 129,402 TKA, 68.8% were white, 16.2% were Hispanic, 8.4% were black, and 6.6% were Asian. Compared to white patients, Hispanic patients had lower risks of septic revision (hazard ratio [HR] = 0.69, 95% confidence interval [CI] = 0.57-0.83) and infection (odds ratio [OR] = 0.42, 95% CI = 0.30-0.59), but a higher likelihood of ED visit (OR = 1.28, 95% CI = 1.22-1.34). Black patients had higher risks of aseptic revision (HR = 1.61, 95% CI = 1.42-1.83), readmission (OR = 1.13, 95% CI = 1.02-1.24), and ED visit (OR = 1.31, 95% CI = 1.23-1.39). Asian patients had lower risks of aseptic revision (HR = 0.67, 95% CI = 0.54-0.83), septic revision (HR = 0.78, 95% CI = 0.60-0.99), readmission (OR = 0.89, 95% CI = 0.79-1.00), and venous thromboembolism (OR = 0.59, 95% CI = 0.45-0.78). CONCLUSION We observed differences in TKA outcome, even within a universally insured population. While lower risks in some outcomes were observed for Asian and Hispanic patients, the higher risks of aseptic revision and readmission for black patients and ED visit for black and Hispanic patients warrant further research to determine reasons for these findings to mitigate disparities. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Adrian D Hinman
- Department of Orthopaedic Surgery, The Permanente Medical Group, San Leandro, CA
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | | | | | - Kanu M Okike
- Department of Orthopaedic Surgery, Kaiser Moanalua Medical Center, Honolulu, HI
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, Harbor City, CA
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Kim SC, Bateman BT. Methodological Challenges in Conducting Large-Scale Real-World Data Analyses on Opioid Use in Musculoskeletal Disorders. J Bone Joint Surg Am 2020; 102 Suppl 1:10-14. [PMID: 32251129 DOI: 10.2106/jbjs.20.00121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Seoyoung C Kim
- Divisions of Pharmacoepidemiology and Pharmacoeconomics (S.C.K. and B.T.B.) and Rheumatology, Inflammation, and Immunity (S.C.K.), and Department of Anesthesiology (B.T.B.), Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Abdallah FW, Gilron I, Fillingim RB, Tighe P, Parvataneni HK, Ghasemlou N, Sawhney M, McCartney CJL. AAAPT Diagnostic Criteria for Acute Knee Arthroplasty Pain. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:1049-1060. [PMID: 32022891 PMCID: PMC8453639 DOI: 10.1093/pm/pnz355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE The relationship between preexisting osteoarthritic pain and subsequent post-total knee arthroplasty (TKA) pain is not well defined. This knowledge gap makes diagnosis of post-TKA pain and development of management plans difficult and may impair future investigations on personalized care. Therefore, a set of diagnostic criteria for identification of acute post-TKA pain would inform standardized management and facilitate future research. METHODS The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) formed the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) initiative to address this goal. A multidisciplinary work group of pain experts was invited to conceive diagnostic criteria and dimensions of acute post-TKA pain. RESULTS The working group used contemporary literature combined with expert opinion to generate a five-dimensional taxonomical structure based upon the AAAPT framework (i.e., core diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms) that characterizes acute post-TKA pain. CONCLUSIONS The diagnostic criteria created are proposed to define the nature of acute pain observed in patients following TKA.
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Affiliation(s)
- Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Ian Gilron
- Department of Anesthesiology & Perioperative Medicine
- Department of Biomedical & Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | | | | | - Hari K Parvataneni
- Department of Orthopedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida, USA
| | - Nader Ghasemlou
- Department of Anesthesiology & Perioperative Medicine
- Department of Biomedical & Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Mona Sawhney
- School of Nursing & Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Colin J L McCartney
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
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Standardized, Patient-specific, Postoperative Opioid Prescribing After Inpatient Orthopaedic Surgery. J Am Acad Orthop Surg 2020; 28:e304-e318. [PMID: 31356424 DOI: 10.5435/jaaos-d-19-00030] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Opioid-related mortality has increased over the past 2 decades, leading to the recognition of a nationwide opioid epidemic and prompting physicians to reexamine their opioid prescribing practices. At our institutions, we had no protocol for prescribing opioids upon discharge after inpatient orthopaedic surgery, resulting in inconsistent and potentially excessive prescribing. Here, we report the results of the implementation of a patient-specific protocol using an opioid taper calculator to standardize opioid prescribing at discharge after inpatient orthopaedic surgery. METHODS The opioid taper calculator is a tool that creates a patient-specific opioid taper based on each patient's 24-hour predischarge opioid utilization. We implemented this taper for patients discharged after inpatient orthopaedic surgery at our two institutions (Boston Medical Center and Lahey Hospital and Medical Center-Burlington Campus). We compared discharge opioid quantities between orthopaedic patients postimplementation and quantities prescribed preimplementation. We also compared discharge opioid quantities between orthopaedic and nonorthopaedic surgical services over the same time period. RESULTS Nine-months postimplementation, a patient-specific taper was used in 74% of eligible discharges, resulting in a 24% reduction in opioids prescribed at discharge, along with a 35% reduction in variance. Over the same time frame, a smaller reduction (9%) was seen in the opioids prescribed at discharge by nonorthopaedic services. The most notable reductions were seen after total joint arthroplasty and spinal fusions. Despite this reduction, most patients (65%) reported receiving sufficient opioids, and no substantial change was observed in 30-day postdischarge opioid prescription refills after versus before protocol implementation (1.58 versus 1.71 fills per discharge). DISCUSSION Using the opioid taper calculator, a patient-specific taper can be successfully used to standardize opioid prescribing at discharge after inpatient orthopaedic surgery without a substantial risk of underprescription. LEVEL OF EVIDENCE Level II.
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Who Is Prescribing Opioids Preoperatively? A Survey of New Patients Presenting to Tertiary Care Adult Reconstruction Clinics. J Am Acad Orthop Surg 2020; 28:301-307. [PMID: 31977344 DOI: 10.5435/jaaos-d-19-00602] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Preoperative opioid use is detrimental to outcomes after hip and knee arthroplasty. This study aims to identify the prevalence of preoperative opioid prescriptions and the specialty and practice setting of the prescriber, as well as the percentage of patients who do not report their opioid prescriptions and any variables associated with preoperative opioid prescriptions. METHODS A total of 461 consecutive new patients evaluated for an arthritic hip or knee were retrospectively studied using institutional data from a tertiary-care, urban center at a university-affiliated private-practice and the state Prescription Monitoring Program to identify opioid prescriptions (including medication, number of pills and dosage, refills, prescriber specialty, and practice setting) within 6 months before their first appointment. Demographic data included age, sex, ethnicity, body mass index, joint, laterality, diagnosis, Charlson Comorbidity Index, duration of symptoms, decision to have surgery, number of days from the first visit to surgery, smoking status, alcohol use, mental health diagnoses, preoperative outcome scores, nonopioid medications, and opioid medications. Patients were separated into opioid and nonopioid cohorts (opioid receivers were further subdivided into those who reported their opioid prescription and those who did not) for statistical analysis to analyze demographic differences using t-tests and Mann-Whitney U tests for continuous variables, the Fisher exact test for categorical variables, and multivariate logistic regression. RESULTS One hundred five patients (22.8%) received an opioid before the appointment. Fifty-two (11.3%) received schedule II or III opioids, 43 (9.3%) received tramadol, and 10 (2.2%) received both. Primary care physicians were the most common prescriber (59.5%, P < 0.001) followed by pain medicine specialists (11.3%) and orthopaedic surgeons (11.3%). More prescribers practiced in the community than academic setting (63.8% versus 36.2%, P < 0.001). Seventy-eight patients (74.3%) self-reported their opioid prescriptions, with the remaining 27 patients (25.7%; 14 schedule II or III opioids and 13 tramadol) identified only after query of the Prescription Monitoring Program. In regression analysis, higher body mass index, diagnosis other than osteoarthritis, and benzodiazepine use were associated with receiving opioids (P < 0.05), while antidepressant use decreased the likelihood of self-reporting opioid prescriptions (P = 0.044). DISCUSSION A striking number of patients are being treated with opioids for hip and knee arthritis. Furthermore, many patients who have received opioids within 6 months do not report their prescriptions. Although primary care physicians prescribed most opioids for nonsurgical treatment of arthritis, a substantial percentage came from orthopaedic surgeons. Further education of physicians and patients on the ill effects of opioids when used for the nonsurgical treatment of hip and knee arthritis is warranted. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Siglin J, Sorkin JD, Namiranian K. Incidence of Postoperative Opioid Overdose and New Diagnosis of Opioid Use Disorder Among US Veterans. Am J Addict 2020; 29:295-304. [PMID: 32202000 DOI: 10.1111/ajad.13022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/17/2020] [Accepted: 02/28/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Perioperative exposure to opioids is associated with adverse outcomes. We aim to determine the associations between surgery and subsequent opioid overdose, an acute event, and a new diagnosis of opioid use disorder (OUD), a chronic relapsing disease, in parallel. METHODS This retrospective cohort study of US veterans used surgery as exposure and the two outcomes were (1) occurrence of overdose and (2) new diagnosis of OUD in the first postoperative year. Surgical group was matched to the reference controls based on the propensity score of having surgery, and matched logistic regression was used to calculate the odds ratio (OR). RESULTS A total of 261 208 surgical patients were matched to 479 531 controls. Overdose occurred in 1893 (0.7%) of the surgical patients and in 518 (0.1%) of the matched controls in the first postoperative year (OR, 6.71; 95% confidence interval [CI], 5.80-7.75; P < .001). Among patients with no history of OUD, surgery was also associated with a new diagnosis of OUD in the first postoperative year (OR, 1.13; 95% CI, 1.02-1.24; P = .015). DISCUSSION AND CONCLUSIONS The postoperative period is strongly associated with opioid overdose, but only weakly associated with new diagnosis of OUD. This is likely due to the difficulty of diagnosing OUD in the postoperative period. SCIENTIFIC SIGNIFICANCE This is the first study that has examined opioid overdose and new-onset OUD in the postoperative period in parallel. Our analysis suggests different risk factors for each, as well as different strengths of association with surgery. More sensitive diagnostic criteria for postoperative OUD are needed to promptly diagnose and treat this condition. (Am J Addict 2020;00:00-00).
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Affiliation(s)
- Jonathan Siglin
- VA Maryland Health Care System, Baltimore, Maryland.,School of Medicine, University of Maryland, Baltimore, Maryland
| | - John D Sorkin
- VA Maryland Health Care System, Baltimore, Maryland.,Baltimore VA Medical Center, Geriatric Research, Education and Clinical Center, VA Maryland Health Care System, Baltimore, Maryland.,Division of Gerontology and Geriatric Medicine, University of Maryland, Baltimore, Maryland
| | - Khodadad Namiranian
- VA Maryland Health Care System, Baltimore, Maryland.,Department of Anesthesiology, University of Maryland, Baltimore, Maryland.,VA Central California Health Care System, Fresno, California
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Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, Mythen M, Miller TE, Shaw AD, Gan TJ, Thacker JKM, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives. Anesth Analg 2020; 129:543-552. [PMID: 30897590 DOI: 10.1213/ane.0000000000003941] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.
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Affiliation(s)
- Michael L Kent
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Robert W Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Gary M Oderda
- College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - Debra B Gordon
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Eric Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Monty Mythen
- University College London National Institute of Health Research (NIHR) Biomedical Research Centre, London, United Kingdom
| | - Timothy E Miller
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Julie K M Thacker
- Division of Advanced Oncologic and Gastrointestinal Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Reid DBC, Shapiro B, Shah KN, Ruddell JH, Cohen EM, Akelman E, Daniels AH. Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty? Clin Orthop Relat Res 2020; 478:205-215. [PMID: 31389888 PMCID: PMC7438153 DOI: 10.1097/corr.0000000000000885] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 06/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the United States, since 2016, at least 28 of 50 state legislatures have passed laws regarding mandatory prescribing limits for opioid medications. One of the earliest state laws (which was passed in Rhode Island in 2016) restricted the maximum morphine milligram equivalents provided in the first postoperative prescription for patients defined as opioid-naïve to 30 morphine milligram equivalents per day, 150 total morphine milligram equivalents, or 20 total doses. While such regulations are increasingly common in the United States, their effects on opioid use after total joint arthroplasty are unclear. QUESTIONS/PURPOSES (1) Are legislative limitations to opioid prescriptions in Rhode Island associated with decreased opioid use in the immediate (first outpatient prescription postoperatively), 30-day, and 90-day periods after THA and TKA? (2) Is this law associated with similar changes in postoperative opioid use among patients who are opioid-naïve and those who are opioid-tolerant preoperatively? METHODS Patients undergoing primary THA or TKA between January 1, 2016 and June 28, 2016 (before the law was passed on June 28, 2016) were retrospectively compared with patients undergoing surgery between June 1, 2017 and December 31, 2017 (after the law's implementation on April 17, 2017). The lapse between the pre-law and post-law periods was designed to avoid confounding from potential voluntary practice changes by physicians after the law was passed but before its mandatory implementation. Demographic and surgical details were extracted from a large multi-specialty orthopaedic group's surgical billing database using Current Procedural Terminology codes 27130 and 27447. Any patients undergoing revision procedures, same-day bilateral arthroplasties, or a second primary THA or TKA in the 3-month followup period were excluded. Secondary data were confirmed by reviewing individual electronic medical records in the associated hospital system which included three major hospital sites. We evaluated 1125 patients. In accordance with the state's department of health guidelines, patients were defined as opioid-tolerant if they had filled any prescription for an opioid medication in the 30-day preoperative period. Data on age, gender, and the proportion of patients who were defined as opioid tolerant preoperatively were collected and found to be no different between the pre-law and post-law groups. The state's prescription drug monitoring program database was used to collect data on prescriptions for all controlled substances filled between 30 days preoperatively and 90 days postoperatively. The primary outcomes were the mean morphine milligram equivalents of the initial outpatient postoperative opioid prescription after discharge and the mean cumulative morphine milligram equivalents at the 30- and 90-day postoperative intervals. Secondary analyses included subgroup analyses by procedure and by preoperative opioid tolerance. RESULTS After the law was implemented, the first opioid prescriptions were smaller for patients who were opioid-naïve (mean 156 ± 106 morphine milligram equivalents after the law's passage versus 451 ± 296 before, mean difference 294 morphine milligram equivalents; p < 0.001) and those who were opioid-tolerant (263 ± 265 morphine milligram equivalents after the law's passage versus 534 ± 427 before, mean difference 271 morphine milligram equivalents; p < 0.001); however, for cumulative prescriptions in the first 30 days postoperatively, this was only true among patients who were previously opioid-naïve (501 ± 416 morphine milligram equivalents after the law's passage versus 796 ± 597 before, mean difference 295 morphine milligram equivalents; p < 0.001). Those who were opioid-tolerant did not have a decrease in the cumulative number of 30-day morphine milligram equivalents (1288 ± 1632 morphine milligram equivalents after the law's passage versus 1398 ± 1274 before, mean difference 110 morphine milligram equivalents; p = 0.066). CONCLUSIONS The prescription-limiting law was associated with a decline in cumulative opioid prescriptions at 30 days postoperatively filled by patients who were opioid-naïve before total joint arthroplasty. This may substantially impact public health, and these policies should be considered an important tool for healthcare providers, communities, and policymakers who wish to combat the current opioid epidemic. However, given the lack of a discernible effect on cumulative opioids filled from 30 to 90 days postoperatively, further investigations are needed to evaluate more effective policies to prevent prolonged opioid use after total joint arthroplasty, particularly in patients who are opioid-tolerant preoperatively. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Daniel B C Reid
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Benjamin Shapiro
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Kalpit N Shah
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Jack H Ruddell
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Eric M Cohen
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Edward Akelman
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Alan H Daniels
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
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Prentice HA, Chan PH, Namba RS, Inacio MC, Sedrakyan A, Paxton EW. Association of Type and Frequency of Postsurgery Care with Revision Surgery after Total Joint Replacement. Perm J 2020; 23:18.314. [PMID: 31926574 DOI: 10.7812/tpp/18.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Postmarket surveillance is limited in the ability to detect medical device problems. Electronic health records can provide real-time information that might help with device surveillance. Specifically, the frequency of postsurgery care might indicate early problems and determine high-risk patients requiring more active surveillance. OBJECTIVE To evaluate whether intensity of postsurgery care is associated with revision risk after total joint arthroplasty (TJA). DESIGN Using an integrated health care system's TJA registry, we identified primary TJA performed between April 2001 and July 2013 (22,953 knees and 9904 hips). Survival analyses evaluated the frequency of specific types of outpatient and inpatient utilization 0 to 90 and 91 to 180 days postoperatively and revision risk. MAIN OUTCOME MEASURES Revision surgery occurring at least 6 months after primary TJA. RESULTS Knee arthroplasty recipients with 3 or more outpatient orthopedic allied health/nurse visits within 90 days had a 2.2 times (95% confidence interval [CI] = 1.6-2.9) higher risk of revision within the first 2 years postoperatively and 10.1 times higher risk (95% CI = 7.6-13.3) after 2 years. Compared with hip arthroplasty recipients who had 0 to 3 visits, patients with 6 or more outpatient orthopedic office visits within 90 days had a 15.7 times (95% CI = 5.7-42.9) higher risk of revision. Similar results were observed for 91-day to 180-day visits. CONCLUSION Future studies are needed to determine if more specific data on reasons for the higher frequency of outpatient visits can refine these findings and elicit more specific recommendations for TJA devices.
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Affiliation(s)
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | | | - Maria Cs Inacio
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Medical College of Cornell University, New York-Presbyterian Hospital, NY
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Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs 2019; 80:9-21. [DOI: 10.1007/s40265-019-01236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Chen EY, Lasky R, Dotterweich WA, Niu R, Tybor DJ, Smith EL. Chronic Prescription Opioid Use Before and After Total Hip and Knee Arthroplasty in Patients Younger Than 65 Years. J Arthroplasty 2019; 34:2319-2323. [PMID: 31255407 DOI: 10.1016/j.arth.2019.05.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/19/2019] [Accepted: 05/28/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Opioids are commonly prescribed to patients with painful and symptomatic degenerative joint disease preoperatively as a nonoperative intervention to reduce patients' symptoms and pain. The goal of total joint arthroplasty (TJA) is to reduce or eliminate the painful symptoms of degenerative joint disease. Due to the addictive property of opioid medications, some patients may develop a pattern of chronic opioid use after TJA. METHODS We used MarketScan Commercial Claims and Encounters database to identify 125,019 patients (age <65 years) who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) between 2009 and 2012. During the study period, opioid use was analyzed 3 months before surgery and at 12 months after surgery. We defined chronic opioid use as having 2 or more opioid prescriptions filled within any 6-week period. Multivariate logistic regression was used. RESULTS Of the 24,127 patients who were chronic prescription opioid users before surgery, 72% were no longer chronic users 1 year after surgery. Of the 100,892 patients who were nonusers before surgery, 4% became chronic users within 1 year after surgery. TKA and hospital stay longer than 3 days were significant risk factors of persisting chronic opioid use after surgery, while age played a mixed role in predicting change of opioid use. CONCLUSION Using our definition of chronic use, overall chronic opioid use decreased from 19% to 9% after TJA. Patients were more likely to cease chronic opioid use after TJA (72%) than to become chronic users (4%).
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Affiliation(s)
- Eric Y Chen
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| | - Rachel Lasky
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA
| | | | - Ruijia Niu
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| | - David J Tybor
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA
| | - Eric L Smith
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
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Prentice HA, Inacio MCS, Singh A, Namba RS, Paxton EW. Preoperative Risk Factors for Opioid Utilization After Total Hip Arthroplasty. J Bone Joint Surg Am 2019; 101:1670-1678. [PMID: 31567804 DOI: 10.2106/jbjs.18.01005] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid prescriptions following orthopaedic procedures may contribute to the opioid epidemic in the United States. Risk factors for greater and prolonged opioid utilization following total hip arthroplasty have yet to be fully elucidated. We sought to determine the prevalence of preoperative and postoperative opioid utilization in a cohort of patients who underwent total hip arthroplasty and to identify preoperative risk factors for prolonged utilization of opioids following total hip arthroplasty. METHODS A cohort study of patients who underwent primary elective total hip arthroplasty at Kaiser Permanente from January 2008 to December 2011 was conducted. The number of opioid prescriptions dispensed per 90-day period after total hip arthroplasty (up to 1 year) was the outcome of interest. The risk factors evaluated included preoperative analgesic medication use, patient demographic characteristics, comorbidities, and other history of chronic pain. Poisson regression models were used, and relative risks (RRs) and 95% confidence intervals (CIs) are presented. RESULTS Of the 12,560 patients who underwent total hip arthroplasty and were identified, 58.5% were female and 78.6% were white. The median age was 67 years (interquartile range, 59 to 75 years). Sixty-three percent of patients filled at least 1 opioid prescription in the 1 year prior to the total hip arthroplasty. Postoperative opioid use went from 88.6% in days 1 to 90 to 24% in the last quarter. An increasing number of preoperative opioid prescriptions was associated with a greater number of prescriptions over the entire postoperative period, with an RR of 1.10 (95% CI, 1.10 to 1.11) at days 271 to 360. Additional factors associated with greater utilization over the entire year included black race, chronic pulmonary disease, anxiety, substance abuse, and back pain. Factors associated with greater utilization in days 91 to 360 (beyond the early recovery phase) included female sex, higher body mass index, acquired immunodeficiency syndrome, peripheral vascular disease, and history of non-specific chronic pain. CONCLUSIONS We identified preoperative factors associated with greater and prolonged opioid utilization long after the early recovery period following total hip arthroplasty. Patients with these risk factors may benefit from targeted multidisciplinary interventions to mitigate the risk of prolonged opioid use. CLINICAL RELEVANCE Opioid prescriptions following orthopaedic procedures are one of the leading causes of chronic opioid use; strategies to reduce the risk of misuse and abuse are needed. At 1 year postoperatively, almost one-quarter of patients who underwent total hip arthroplasty used opioids in the last 90 days of the first postoperative year, which makes understanding risk factors associated with postoperative opioid utilization imperative.
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Affiliation(s)
- Heather A Prentice
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Maria C S Inacio
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California.,Registry of Older South Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Division of Health Sciences, Sansom Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Anshuman Singh
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, California
| | - Robert S Namba
- Department of Orthopaedics, Southern California Permanente Medical Group, Irvine, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
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Gardner V, Gazzaniga D, Shepard M, Grumet R, Rubin B, Dempewolf M, Bray C, Prietto C. Monitoring Postoperative Opioid Use Following Simple Arthroscopic Meniscectomy: A Performance-Improvement Strategy for Prescribing Recommendations and Community Safety. JB JS Open Access 2018; 3:e0033. [PMID: 30882058 PMCID: PMC6400509 DOI: 10.2106/jbjs.oa.18.00033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Orthopaedic surgeons are confronted with a difficult dilemma: managing acute pain postoperatively and balancing the risk of prescription opioid use. To our knowledge, a prospective performance-improvement project providing opioid-prescription recommendations based on the actual amounts of usual and customary medication consumed following simple knee meniscectomy has not been described. Methods: One hundred and two patients undergoing arthroscopic knee meniscectomy prospectively recorded postoperative pain medications in a pain journal. Arthroscopic procedures were performed at 2 centers by 9 fellowship-trained senior surgeons. Various usual and customary prescribing protocols were observed, and the amount of medication consumed was recorded. Prescription and over-the-counter pain medication, quantity, frequency, and visual analog scale (VAS) pain scores were collected. Results: One hundred and two patients filled a prescription opioid medication and were included in the study. A total of 3,765 pills were prescribed, and a total of 573.5 were consumed. For the 102 patients who filled a prescription, the average time consuming opioid medication was 2 ± 2 days (range, 0 to 13 days) postoperatively. No cases of persistent use were recorded. Of the 102 patients who filled a prescription, 29.4% did not take any prescription opioids postoperatively. A total of 3,191.5 pills (or 22,183.75 morphine milligram equivalents [MME]) were unused and were potentially available to the community. Conclusions: Following simple knee arthroscopy, the amount of prescribed opioid medication exceeds the need for postoperative pain management. In general, 68% of patients require a maximum of 13 pills postoperatively for 6 days. Surgeons should adjust prescribing standards accordingly to limit the amount of prescription opioids available to the community. Furthermore, a comprehensive response to include increased patient screening and monitoring as well as opioid use and disposal education is recommended.
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Dindo L, Zimmerman MB, Hadlandsmyth K, StMarie B, Embree J, Marchman J, Tripp-Reimer T, Rakel B. Acceptance and Commitment Therapy for Prevention of Chronic Postsurgical Pain and Opioid Use in At-Risk Veterans: A Pilot Randomized Controlled Study. THE JOURNAL OF PAIN 2018; 19:1211-1221. [PMID: 29777950 PMCID: PMC6163061 DOI: 10.1016/j.jpain.2018.04.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/18/2018] [Accepted: 04/30/2018] [Indexed: 12/16/2022]
Abstract
High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in "at-risk" veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n = 44) or TAU plus a 1-day ACT workshop (n = 44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals. PERSPECTIVE This pilot study compared the effects of a 1-day preventive behavioral intervention (ACT) to TAU in at-risk veterans undergoing orthopedic surgery. Three months following the intervention, veterans receiving ACT exhibited quicker cessation of pain and opioid use. Focusing on preoperative pain management may help prevent chronic postsurgical pain.
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Affiliation(s)
- Lilian Dindo
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas; Center for Innovations, Quality, and Effectiveness, Michael E. Debakey Veterans Affairs Medical Center, Houston, Texas.
| | | | | | | | - Jennie Embree
- College of Nursing, University of Iowa, Iowa City, Iowa
| | - James Marchman
- Department of Psychology, University of Iowa, Iowa City, Iowa
| | | | - Barbara Rakel
- College of Nursing, University of Iowa, Iowa City, Iowa
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Preoperative opioid medication use negatively affect health related quality of life after total knee arthroplasty. Knee 2018; 25:946-951. [PMID: 30108011 DOI: 10.1016/j.knee.2018.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/09/2018] [Accepted: 07/02/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Opioids are commonly prescribed to treat patients suffering from painful knee arthritis. However, the opioid epidemic in the United States constitutes a major public health concern. This study aims to characterize the effect of preoperative opioid use on patient-reported outcome measures (PROMs) after total knee arthroplasty (TKA). METHODS PROMs collected from patients undergoing TKA were reviewed. We identified two matched cohorts: (1) 30 patients who used opioids preoperatively and (2) 137 patients who did not use opioids preoperatively. The non-opioid cohort was carefully selected to match the opioid cohort. Statistical analyses were performed to determine the difference in demographics, PROMs, length of stay, disposition and co-morbidities between the two cohorts. RESULTS The non-opioid users had significant improvement in both EuroQol5D (EQ-5D) PROMs and visual analogy scale (VAS) scores postoperatively (p < 0.001); however, preoperative opioid users did not show improvement in either measure. University of California Los Angles (UCLA) scores were significantly improved for both non-opioid users (p < 0.001) and opioid users (p < 0.001). Non-opioid users had higher preoperative EQ-5D scores than opioid users (p = 0.02). There was no difference in range of motion, length of stay, or disposition between cohorts. CONCLUSION Our results demonstrated that TKA patients with preoperative opioid use had significantly lower VAS scores and trends of lower UCLA and EQ-5D scores postoperatively compared to non-opioid patients, suggesting the use of opioid medications prior to TKA negatively affects patient reported outcomes following surgery. The current findings provide useful clinical information that can be used in counseling patients prior to undergoing TKA.
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Edwards PK, Mears SC, Stambough JB, Foster SE, Barnes CL. Choices, Compromises, and Controversies in Total Knee and Total Hip Arthroplasty Modifiable Risk Factors: What You Need to Know. J Arthroplasty 2018; 33:3101-3106. [PMID: 29573920 DOI: 10.1016/j.arth.2018.02.066] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 02/14/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Total joint arthroplasty has historically been very successful for most patients, yet some still incur a complication. In an era of value-based care, certain efforts need to be taken to optimize patients' risk profile before surgery to decrease the chances of readmission or surgical complication. METHODS We reviewed 10 key medical conditions and lifestyle factors that surgeons should improve before pursuing total joint arthroplasty and provide a summary of the available literature to guide certain optimization thresholds. RESULTS With careful attention to and the creation of a preoperative checklist, surgeons can identify key domains, including morbid obesity, malnutrition, diabetes, smoking, opioid use, poor dentition, cardiovascular disease, preoperative anemia, staphylococcus colonization, and psychological disorders and intervene based on an individual's areas of deficiencies. CONCLUSION By following stringent protocols and rescheduling surgery until optimization has occurred, we can work to provide patients the best chance for a successful outcome with an elective hip or knee arthroplasty.
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Affiliation(s)
- Paul K Edwards
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Sara E Foster
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
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Rubenstein W, Grace T, Croci R, Ward D. The interaction of depression and prior opioid use on pain and opioid requirements after total joint arthroplasty. Arthroplast Today 2018; 4:464-469. [PMID: 30560177 PMCID: PMC6287236 DOI: 10.1016/j.artd.2018.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 11/24/2022] Open
Abstract
Background Preoperative opioid use causes increased pain and opioid requirements after total joint arthroplasty (TJA), but the effect of depression on this relationship is not well defined. Methods We conducted a retrospective review of primary TJA patients using an institutional database. Demographic variables, inpatient opioid requirements, and discharge prescription quantities were collected and compared between patients with and without a prior diagnosis of depression in both the prior opioid-using and nonusing cohorts. Results Four hundred and three patients were analyzed between August 1, 2016, and July 31, 2017. Among prior opioid users, patients with depression experienced higher inpatient pain levels (4 vs 3; P = .001), required more inpatient opioids (117 oral morphine equivalents [OMEs] vs 70 OMEs; P = .022), were prescribed more opioids at discharge (1163 OMEs vs 750 OMEs; P = .02), and required more long-term opioid refills (57.7% vs 15.4%; P < .001) than patients without depression. However, depression was not associated with increased pain, opioid requirements, prescription quantities, or refill rates among opioid-naive patients. Conclusions Depression is not associated with increased pain or opioid requirements among opioid-naive patients after TJA but is associated with significantly higher pain and opioid requirements among patients who use opioids preoperatively. The interaction of these variables may highlight a target for preoperative counseling and risk modification in the arthroplasty population.
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Affiliation(s)
- William Rubenstein
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, USA
| | - Trevor Grace
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, USA
| | - Rhiannon Croci
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, USA
| | - Derek Ward
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, USA
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Halawi MJ, Lieberman JR. Opioids in Total Joint Arthroplasty: Moving Forward. J Arthroplasty 2018; 33:2341-2343. [PMID: 29903460 DOI: 10.1016/j.arth.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/01/2018] [Accepted: 06/04/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- Mohamad J Halawi
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
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Ilfeld BM, Ball ST, Gabriel RA, Sztain JF, Monahan AM, Abramson WB, Khatibi B, Said ET, Parekh J, Grant SA, Wongsarnpigoon A, Boggs JW. A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty. Neuromodulation 2018; 22:653-660. [PMID: 30024078 PMCID: PMC6339601 DOI: 10.1111/ner.12790] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/19/2018] [Accepted: 04/09/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA). METHODS For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total. RESULTS In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported. CONCLUSIONS This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Scott T Ball
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Amanda M Monahan
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Jesal Parekh
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Stuart A Grant
- Duke University Medical Center, Duke University, Durham, NC, USA
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Weick J, Bawa H, Dirschl DR, Luu HH. Preoperative Opioid Use Is Associated with Higher Readmission and Revision Rates in Total Knee and Total Hip Arthroplasty. J Bone Joint Surg Am 2018; 100:1171-1176. [PMID: 30020122 DOI: 10.2106/jbjs.17.01414] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prescription opioid use is epidemic in the U.S. Recently, an association was demonstrated between preoperative opioid use and increased health-care utilization following abdominal surgeries. Given that primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) are 2 of the most common surgical procedures in the U.S., we examined the association of preoperative opioid use with 30-day readmission and early revision rates. METHODS We reviewed 2003 to 2014 data from 2 Truven Health MarketScan databases (commercial insurance and Medicare plus commercial supplemental insurance). Subjects were included if they had a Current Procedural Terminology (CPT) code for primary TKA or THA and were continuously enrolled in the database for at least 6 months prior to the index procedure. Preoperative opioid prescriptions were identified using National Drug Codes (NDCs). Rates of 30-day readmissions and revision arthroplasty were identified and compared among patients with stratified durations of preoperative opioid use in the 6 months preceding TKA or THA. RESULTS The study included 324,154 patients in the 1-year follow-up group and 159,822 patients in the 3-year follow-up group. Opioid-naive TKA patients had a lower revision rate than did those with >60 days of preoperative opioid use (1-year cohort: 1.07% compared with 2.14%, p < 0.001; 3-year cohort: 2.58% compared with 5.00%, p < 0.001). A similar trend was noted among THA patients (1-year: 0.38% compared with 1.10%, p < 0.001; 3-year: 1.24% compared with 2.99%, p < 0.001). These trends persisted after adjusting for age, sex, and Charlson Comorbidity Index (CCI). The 30-day readmission rate after TKA or THA was significantly lower for patients with no preoperative opioid use compared with those with >60 days of preoperative opioid use (TKA: 4.82% compared with 6.17%, p < 0.001; THA: 3.71% compared with 5.85%, p < 0.001). Again, this association persisted after adjusting for age, sex, and CCI. CONCLUSIONS Preoperative opioid use was associated with significantly increased risk of early revision and significantly increased risk of 30-day readmission after TKA and THA. This study illustrates the increased risk of poor outcomes and increased postoperative health-care utilization for patients with long-term opioid use prior to THA and TKA. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jack Weick
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, Illinois
| | - Harpreet Bawa
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, Illinois
| | - Douglas R Dirschl
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, Illinois
| | - Hue H Luu
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, Illinois
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50
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Allen KD, Golightly YM, White DK. Gaps in appropriate use of treatment strategies in osteoarthritis. Best Pract Res Clin Rheumatol 2018; 31:746-759. [PMID: 30509418 DOI: 10.1016/j.berh.2018.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 10/28/2022]
Abstract
Optimal management of osteoarthritis (OA) requires a combination of therapies, with behavioral (e.g., exercise and weight management) and rehabilitative components at the core, accompanied by pharmacological treatments and, in later stages, consideration of joint replacement surgery. Although multiple sets of OA treatment guidelines have been developed, there are gaps in the implementation of these recommendations. Key areas of concern include the underuse of exercise, weight management, and other behavioral and rehabilitation strategies as well as the overuse of opioid analgesics. In this review, we describe the major categories of treatment strategies for OA, including self-management, physical activity, weight management, physical therapy and other rehabilitative therapies, pharmacotherapies, and joint replacement surgery. For each category, we discuss the current evidence base to report on appropriate use, data regarding adherence to treatment recommendations, and potential approaches to optimize use.
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Affiliation(s)
- Kelli D Allen
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina, Center for Health Services Research in Primary Care, Department of Veterans Affairs Center, Durham, NC, USA.
| | - Yvonne M Golightly
- Department of Epidemiology, Gillings School of Global Public Health/Division of Physical Therapy/Thurston Arthritis Research Center, School of Medicine/Injury Prevention Research Center, University of North Carolina, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC 27599-7280, USA.
| | - Daniel K White
- Department of Physical Therapy University of Delaware, 540 South College Ave, 210L, Newark, DE, 19713, USA.
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