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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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Batko BD, Ippolito JA, Gupta A, Bukowiec L, Potter JS, Joshi T, Kissin YD. Synergistic effects of robotic surgery and IPACK nerve block on reduction of opioid consumption in total knee arthroplasty. J Orthop 2022; 34:226-232. [PMID: 36120477 PMCID: PMC9474319 DOI: 10.1016/j.jor.2022.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 11/30/2022] Open
Abstract
Background There are numerous strategies to combat postoperative analgesia and expedite recovery after total knee arthroplasty (TKA). The purpose of this study was to determine opioid consumption, length of stay, and functional outcomes after robotic versus standard TKA in the setting of various regional pain modalities. Methods A consecutive series of patients treated with unilateral primary robotic or standard TKA from January 2018-February 2021 were retrospectively identified. Regional pain modalities included peri-articular injection (PAI), adductor canal block (ACB), and infiltration between popliteal artery and capsule of knee (IPACK). Patient demographics, operative/perioperative variables, and postoperative function were recorded. Daily opiate consumption was calculated as morphine milligram equivalents (MME). Multivariate regression was performed to control for age, sex, and race. Results After review, 283 patients (177 Females; 106 Males) were included. Robotic TKA patients received IPACK + ACB (36), while standard TKA patients received either ACB (45), IPACK + ACB (167), or PAI (35). Daily inpatient opioid consumption in the standard IPACK + ACB (p = 0.02) and robotic IPACK + ACB groups (p = 0.0001) was significantly lower compared to standard ACB. When combined with IPACK block, robotic procedures synergistically lowered opiate consumption (p = 0.004) compared to standard procedures and led to earlier discharge (p = 0.003). The robotic IPACK + ACB cohort also demonstrated improved early ambulation compared to standard ACB, (p = 0.05), whereas the same benefit was not seen for patients who received IPACK during standard TKA. Conclusions The utilization of IPACK block decreases inpatient postoperative opioid requirements following TKA. Robotic TKA and IPACK block appeared to have a synergistic effect on opioid consumption and postoperative recovery.
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Key Words
- ACB, adductor canal block
- ANOVA, analysis of variance
- ASA, American Society of Anesthesiologists
- BMI, body mass index
- CI, confidence interval
- FNB, femoral nerve block
- IPACK, infiltration between the popliteal artery and the capsule of the knee
- Infiltration between popliteal artery and capsule of knee (IPACK) block
- LOS, length of stay
- MME, morphine milligram equivalents
- NJPMP, New Jersey Prescription Monitoring Program
- Opioids
- PAI, periarticular injection
- ROM, range of motion
- Regional anesthesia
- Robotic surgery
- SD, standard deviation
- TKA, total knee arthroplasty
- Total knee arthroplasty (TKA)
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Affiliation(s)
- Brian D Batko
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ, 07103, USA
| | - Joseph A Ippolito
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ, 07103, USA
| | - Arjun Gupta
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ, 07103, USA
| | - Lainey Bukowiec
- Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, 340 Kingsland Street, Nutley, NJ, 07110, USA
| | - James S Potter
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ, 07103, USA
| | - Tej Joshi
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ, 07103, USA
| | - Yair D Kissin
- Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, 340 Kingsland Street, Nutley, NJ, 07110, USA
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Abstract
BACKGROUND Mohs micrographic surgery (MMS) is a widely used technique for removal of cutaneous tumors. The procedure is well-tolerated with little surgical or postoperative pain. OBJECTIVE This study examined pain levels after Mohs surgery throughout the first week of recovery and the relation to patient demographics, lesion characteristics, surgery details, and postoperative analgesia. METHODS A 2-year prospective observational study included patients who underwent MMS. Patients rated the severity of postoperative pain once daily until removal of sutures and documented analgesics used. Analyses of patient and lesion characteristics along with reconstruction methods were conducted. RESULTS A total of 2,178 patients were included in the study. Pain levels were strongest on the first postoperative day (POD) and were significantly different between genders on POD 3. Site of skin lesion, method of reconstruction, and number of stages of MMS were significantly related to postoperative pain levels on univariate and multivariate analyses. Postoperative consumption of analgesics differed significantly between men and women and was not correlated to age. CONCLUSION Mohs surgery is generally nonpainful and is well-tolerated by men and women across all ages. The site of the lesion and method of reconstruction are the major determinants affecting the perception of pain.
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Lovecchio F, Premkumar A, Steinhaus M, Alexander K, Mejia D, Yoo JS, Lafage V, Iyer S, Huang R, Lebl D, Qureshi S, Kim HJ, Singh K, Albert T. Early Opioid Consumption Patterns After Anterior Cervical Spine Surgery. Clin Spine Surg 2022; 35:E121-E126. [PMID: 33783369 DOI: 10.1097/bsd.0000000000001176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a prospective observational study. OBJECTIVE The aim was to record daily opioid use and pain levels after 1-level or 2-level anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA). SUMMARY OF BACKGROUND DATA Data to inform opioid prescription guidelines following ACDF or CDA is lacking. Understanding postoperative opioid consumption behaviors is critical to provide appropriate postdischarge prescriptions. METHODS Patients undergoing 1-level or 2-level primary ACDF or CDA were consecutively enrolled at 2 participating institutions between March 2018 and March 2019. Patients with opioid dependence (defined as daily use ≥6 mo before surgery) were excluded. Starting postoperative day 1, daily opioid use and numeric pain rating scale pain levels were collected through a Health Insurance Portability and Accountability Act-compliant, automated text-messaging system. To facilitate clinical applications, opioid use was converted from oral morphine equivalents into "pills" (oxycodone 5 mg equivalents). After 6 weeks or upon patient-reported cessation of opioid use, final survey questions were asked. Refill data were verified from the state prescription registry. Risk factors for patients in top quartile of consumption were analyzed. RESULTS Of 57 patients, 48 completed the daily queries (84.2%). Mean age of the patient sample was 50.2±10.9 years. Thirty-two patients (66.7%) underwent ACDF and 16 CDA (33.3%); 64.6% one level; 35.4% two levels. Median postdischarge use was 6.7 pills (range: 0-160). Cumulative opioid use did not vary between the 1-level and 2-level groups (median pill consumption, 10 interquartile range: 1.3-31.3 vs. 4 interquartile range: 0-18, respectively, P=0.085). Thirteen patients (27.1%) did not use any opioids after discharge. Of those patients that took opioids after discharge, half ceased opioids by postoperative day 8. Preoperative intermittent opioid use was associated with the top quartile of opioid consumption (9.1% vs. 50%, P=0.006). CONCLUSION Given that most patients use few opioids, patients could be offered the option of a 12 oxycodone 5 mg (90 oral morphine equivalents) discharge prescription, accompanied by education on appropriate opioid use and disposal.
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Affiliation(s)
| | | | | | | | | | - Joon S Yoo
- Midwest Orthopaedics at Rush, Chicago, IL
| | | | | | | | | | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | - Kern Singh
- Midwest Orthopaedics at Rush, Chicago, IL
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Preoperative Opioid Use Predicts Postoperative Opioid Use and Inferior Clinically Notable Outcomes After Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2022; 30:e242-e251. [PMID: 34644714 DOI: 10.5435/jaaos-d-21-00319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 09/02/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Preoperative opioid use (OU) may negatively affect outcomes after total shoulder arthroplasty (TSA). This study aims to evaluate the influence of preoperative OU on achievement of midterm clinically notable outcomes (CSOs) after TSA and identify factors associated with prolonged postoperative OU and persistent pain after TSA. METHODS Using a single-institution, prospectively collected TSA registry, we retrospectively identified patients who underwent surgery between 2014 and 2019. Subjects were stratified into two cohorts: preoperative OU within 12 months of surgery and opioid naive (N-OU) patients. Minimum 1-year postoperative scores and achievement of CSOs patient-reported outcome measures (PROMs), as well as predictors of postoperative OU and persistent pain, were analyzed. RESULTS A total of 817 patients were included with 706 patients in the N-OU cohort and 111 patients in the OU cohort. Although both patients in the N-OU and OU cohorts showed statistically significant improvements at the 1-year follow-up, absolute PROM scores were less favorable in the OU cohort (all P < 0.05). Preoperative opioid users were significantly less likely to achieve minimal clinically important difference (odds ratios [ORs]: 0.47 to 2.4, all P < 0.05) and patient acceptable symptomatic state (ORs: 0.41 to 2.12, all P < 0.05) on the American Shoulder and Elbow Surgeon, Single Assessment Numeric Evaluation, Constant-Murley Shoulder Score, Visual Analogue Scale (VAS) pain, Veterans Rand 12-Item Health Survey, Short-Form 12-Item Health Survey, and Veterans Rand 6D and substantial clinical benefit (OR: 0.50 to 0.56, P < 0.05) on the American Shoulder and Elbow Surgeon and Single Assessment Numeric Evaluation. Preoperative OU significantly predicted increased OU at 6 months (OR: 7.11, P = 0.009) and 1-year follow-up (OR: 40.23, P < 0.001) and persistent pain at 1 year (OR: 2.37, P = 0.001). CONCLUSION Preoperative OU markedly correlated with worse PROMs at 1 year postoperatively. Although preoperative opioid users demonstrate improvement in functional-related and health-related quality-of-life PROMs after TSA, they are markedly less likely to achieve CSOs and were more likely to report persistent pain and continued OU at 6-month and 1-year follow-ups. Opioid users undergoing TSA should be counseled regarding their expected outcomes, and preventive measures should aim to limit prolonged OU/abuse after surgery. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Genetic and other associations with pain: a literature review of potential identifiers for significant pain after total knee arthroplasty. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mallama CA, Greene C, Alexandridis AA, McAninch J, Dal Pan G, Meyer T. Patient-reported opioid analgesic use after discharge from surgical procedures: a systematic review. PAIN MEDICINE 2021; 23:29-44. [PMID: 34347101 DOI: 10.1093/pm/pnab244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This systematic review synthesizes evidence on patient-reported outpatient opioid analgesic use post-surgery. METHODS We searched Pubmed (February 2019), Web of Science and Embase (June 2019) for U.S. studies describing patient-reported outpatient opioid analgesic use. Two reviewers extracted data on opioid analgesic use, standardized use, and performed independent quality appraisals based on the Cochrane Risk of Bias Tool and an adapted Newcastle-Ottawa scale. RESULTS Ninety-six studies met eligibility criteria; 56 had sufficient information to standardize use in oxycodone 5 mg tablets. Patient-reported opioid analgesic use varied widely by procedure type; knee and hip arthroplasty had the highest postoperative opioid use, and use after many procedures was reported as < 5 tablets. In studies that examined excess tablets, 25%-98% of the total tablets prescribed were reported to be excess, with most studies reporting that 50%-70% of tablets went unused. Factors commonly associated with higher opioid analgesic use included preoperative opioid analgesic use, higher inpatient opioid analgesic use, higher postoperative pain scores, and chronic medical conditions, among others. Estimates also varied across studies due to heterogeneity in study design, including length of follow-up and inclusion/exclusion criteria. CONCLUSION Self-reported post-surgery outpatient opioid analgesic use varies widely both across procedures and within a given procedure type. Contributors to within-procedure variation included patient characteristics, prior opioid use, intraoperative and perioperative factors, and differences in timing of opioid use data collection. We provide recommendations to help minimize variation caused by study design factors and maximize interpretability of forthcoming studies for use in clinical guidelines and decision-making.
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Affiliation(s)
- Celeste A Mallama
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Christina Greene
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Apostolos A Alexandridis
- Office of Science, Center for Tobacco Products, United States Food and Drug Administration, Silver Spring MD, USA. The work presented here was conducted while an ORISE fellow with the Center for Drug Evaluation and Research
| | - Jana McAninch
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Gerald Dal Pan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Tamra Meyer
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
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Eccles CJ, Swiergosz AM, Smith AF, Bhimani SJ, Smith LS, Malkani AL. Decreased Opioid Consumption and Length of Stay Using an IPACK and Adductor Canal Nerve Block following Total Knee Arthroplasty. J Knee Surg 2021; 34:705-711. [PMID: 31683348 DOI: 10.1055/s-0039-1700840] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Peripheral nerve blocks such as a femoral + sciatic block have demonstrated significant pain relief following TKA. However, these nerve blocks have residual motor deficits which prevent immediate postoperative ambulation. The purpose of this study was to compare outcomes in patients undergoing primary TKA with femoral and sciatic (Fem + Sci) motor nerve blocks versus an adductor canal and the interspace between the popliteal artery and the capsule of the posterior knee and adductor canal block (IPACK + ACB) sensory nerve blocks. A total of 100 consecutive patients were reviewed, 50 received Fem + Sci nerve blocks and 50 received IPACK + ACB blocks preoperatively. There were no differences in the two groups with respect to surgical technique, implant type, postoperative pain, and physical therapy protocols. Differences in opioid requirements, length of stay (LOS), distance walked, and common knee scoring systems were analyzed. Among them, 62% IPACK + ACB patients were discharged on postoperative day 1 compared with 14% in the Fem + Sci group (p < 0.0001). The IPACK + ACB patients had a shorter LOS (mean 1.48 days vs. 2.02 days, p < 0.001), ambulated further on postoperative day 0 (mean 21.4 feet vs. 5.3 feet, p < 0.001), and required less narcotics the day after surgery (mean, 15.7 vs. 24.0 morphine equivalents p < 0.0001) and at 2 weeks (mean, 6.2 vs. 9.3 morphine equivalents, p = 0.025). The use of this combination IPACK and ACB demonstrated improved early ambulation with a decrease in opioid use and length of stay compared with a femoral and sciatic motor nerve block in patients undergoing primary TKA.
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Affiliation(s)
- Christian J Eccles
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
| | - Andrew M Swiergosz
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
| | - Austin F Smith
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
| | - Samrath J Bhimani
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
| | - Langan S Smith
- Orthopedic Associates, KentuckyOne Health Medical Group, Louisville, Kentucky
| | - Arthur L Malkani
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
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Davey MS, Hurley ET, Anil U, Moses A, Thompson K, Alaia M, Strauss EJ, Campbell KA. Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis. Arthroscopy 2021; 37:1290-1300.e6. [PMID: 33515736 DOI: 10.1016/j.arthro.2021.01.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes. METHODS A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable. RESULTS Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. CONCLUSIONS Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use. LEVEL OF EVIDENCE Level II, systematic review and meta-analysis of RCTs.
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Affiliation(s)
- Martin S Davey
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A.; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eoghan T Hurley
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A.; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Utkarsh Anil
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Akini Moses
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kamali Thompson
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Michael Alaia
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Eric J Strauss
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kirk A Campbell
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
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Samuel AM, Lovecchio FC, Premkumar A, Louie PK, Vaishnav AS, Iyer S, McAnany SJ, Albert TJ, Gang CH, Qureshi SA. Use of Higher-strength Opioids has a Dose-Dependent Association With Reoperations After Lumbar Decompression and Interbody Fusion Surgery. Spine (Phila Pa 1976) 2021; 46:E203-E212. [PMID: 33079910 DOI: 10.1097/brs.0000000000003751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to identify an association between preoperative opioid use and reoperations rates. SUMMARY OF BACKGROUND DATA Chronic opioid use is a public health crisis in the United States and has been linked to worse outcomes after lumbar spine surgery. However, no studies have identified an association between preoperative opioid use and reoperations rates. METHODS A retrospective cohort study was conducted using patients from one private insurance database who underwent primary lumbar decompression/discectomy (LDD) or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Preoperative use of five specific opioid medications (tramadol, hydromorphone, oxycodone, hydromorphone, and extended-release oxycodone) was categorized as acute (within 3 months), subacute (acute use and use between 3 and 6 months), or chronic (subacute use and use before 6 months). Multivariate regression, controlling for multilevel surgery, age, sex, and Charlson Comorbidity Index, was used to determine the association of each medication on reoperations within 5 years. RESULTS A total of 11,551 patients undergoing LDD and 3291 patients undergoing PLIF/TLIF without previous lumbar spine surgery were identified. In the LDD group, opioid-naïve patients had a 5-year reoperation rate of 2.8%, compared with 25.0% and 8.0 with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of oxycodone was associated with increased reoperations (odds ratios [OR] = 1.4, 2.0, and 2.3, for acute, subacute, and chronic use; P < 0.01). Chronic use of hydromorphone was also associated with increased reoperations (OR = 7.5, P < 0.01).In the PLIF/TLIF group, opioid-naïve patients had a 5-year reoperation rate of 11.3%, compared with 66.7% and 16.8% with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of hydromorphone was associated with increased reoperations (OR = 2.9, 4.0, and 14.0, for acute, subacute, and chronic use; P < 0.05). CONCLUSION Preoperative use of the higher-potency opioid medications is associated with increased reoperations after LDD and PLIF/TLIF in a dose-dependent manner. Surgeons should use this data for preoperative opioid cessation counseling and individualized risk stratification.Level of Evidence: 3.
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Affiliation(s)
| | | | | | | | | | - Sravisht Iyer
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | - Steven J McAnany
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | - Todd J Albert
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
| | | | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY, USA
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Reduction of Opioids Prescribed Upon Discharge After Total Knee Arthroplasty Significantly Reduces Consumption: A Prospective Study Comparing Two States. J Arthroplasty 2021; 36:160-163. [PMID: 32778420 DOI: 10.1016/j.arth.2020.07.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Opioids prescribed for acute pain after total knee arthroplasty (TKA) play a contributing role in the number of opioid pills in circulation. At the height of an opioid epidemic in the United States, opioids are increasingly diverted, misused, and abused. Therefore, many states have enacted narcotic regulations in an attempt to curb opioid diversion and misuse. The purpose of this study is to evaluate the effect of stricter state prescribing regulations on opioid consumption following TKA. METHODS In total, 165 opioid-naive patients undergoing primary unilateral TKA at a single institution with a standardized perioperative pain protocol were reviewed. Seventy-one patients (group 1) resided in a state with strict opioid regulations that limit the initial number of pills dispensed and refills, whereas 92 patients (group 2) resided in another state without quantity and refill regulations. Patient demographics were similar between the 2 groups. Mean age was 64 and mean body mass index was 32 kg/m2. Opioid consumption, quantity, and refill patterns were collected for 6 weeks following surgery. RESULTS The average oral morphine equivalents consumed during the 6 weeks postsurgery were significantly lower in group 1 at 446.3 ± 266.3 mg (range 10-992) compared to group 2 at 622.6 ± 313.7 mg (range 20-1416) (P < .001). The average oral morphine equivalent corresponds to 60 tablets of 5 mg oxycodone per patient in group 1 vs 84 tablets per patient in group 2. Fifty-nine (83%) patients in group 1 had stopped taking opioids within 6 weeks of surgery compared to 59 (64%) in group 2 (P = .04). CONCLUSION Based on our results, the institution of state regulations aimed at decreasing the quantity and refills of postoperative opioids led patients to consume less opioids following TKA. Many patients are prescribed more opioids than they require which increases their consumption and can increase the risk for diversion, addiction, and misuse. LEVEL OF EVIDENCE Level III; retrospective comparative cohort study.
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Beck EC, Nwachukwu BU, Jan K, Krivicich LM, Chahla J, Fu MC, Nho SJ. The Effect of Postoperative Opioid Prescription Refills on Achieving Meaningful Clinical Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Arthroscopy 2020; 36:1599-1607. [PMID: 32061972 DOI: 10.1016/j.arthro.2020.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether requiring postoperative opioid refills has an effect on both baseline and postoperative functional scores, as well as rates of achieving clinical success 2 years after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS Data from consecutive patients undergoing hip arthroscopy for FAIS from January 2012 to December 2016 were analyzed. Patients with at least 1 postoperative opioid refill were matched 1:2 by age and body mass index to patients not requiring refills. Preoperative and postoperative patient-reported outcomes including the Hip Outcome Score-Activities of Daily Living Subscale, HOS-Sports Subscale, and modified Hip Harris Score, as well as visual analog scale (VAS) pain and satisfaction surveys, were compared between the 2 groups, as well as between patients who requested 1 refill versus those requiring 2 or more refills. The minimal clinically important difference and patient acceptable symptomatic state (PASS) were calculated for the study group and compared between patient groups. RESULTS A total of 128 patients (14.5%) requesting at least 1 postoperative opioid refill and 256 with no refills were included in the study. Analysis showed that the refill group had lower patient-reported outcomes (P < .05 for all), a lower VAS satisfaction score average (73.2 ± 30.7 vs 80.1 ± 25.9, P = .029), and a higher VAS pain score average (27.2 ± 26.1 vs 19.9 ± 22.7, P = .007). Similar trends were seen when patients with 1 refill were compared with those with 2 or more refills. Analysis of meaningful clinical outcomes showed that patients in the refill group had lower rates of achieving the PASS (68.3% vs 77.2%, P = .006). However, there were no statistically significant differences in achieving the minimal clinically important difference between the 2 groups (P > .05 for all). CONCLUSIONS Patients undergoing hip arthroscopy for FAIS who require 1 or more opioid refills postoperatively are likely to have lower baseline and postoperative functional scores, as well as to achieve the PASS at lower rates, compared with patients who do not require an additional opioid prescription to what is routinely given after surgery. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A..
| | - Benedict U Nwachukwu
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Kyleen Jan
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Laura M Krivicich
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Michael C Fu
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Lovecchio F, Premkumar A, Uppstrom T, Stepan J, Ammerman B, McCarthy M, Stein BS, Pearle A, Taylor S, Kumar K, Albert T, Hannafin J. Opioid Consumption After Arthroscopic Meniscal Procedures and Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2020; 8:2325967120913549. [PMID: 32426402 PMCID: PMC7219018 DOI: 10.1177/2325967120913549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/23/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Procedure-specific opioid-prescribing guidelines have the potential to decrease the number of unused pills in the home without compromising patient satisfaction. However, there is a paucity of data on the minimum necessary quantity to prescribe for outpatient orthopaedic surgeries. Purpose: To prospectively record daily opioid use and pain levels after arthroscopic meniscal procedures and anterior cruciate ligament reconstruction (ACLR) at a single institution. Study Design: Case series; Level of evidence, 4. Methods: A total of 95 adult patients who underwent primary arthroscopic knee surgery (meniscectomy, repair, or ACLR) were enrolled. Patients with a history of opioid dependence were ineligible. Daily opioid consumption and Numeric Rating Scale pain scores were collected through an automated text-messaging platform starting on postoperative day 1 (POD1). At 6 weeks or at patient-reported cessation of opioid use, final survey questions were asked. Patients who failed to complete data collection were excluded. Opioid use was converted into “pills” (oxycodone 5-mg equivalents) to facilitate comparisons and clinical applications. Factors associated with high and low opioid use were compared. Results: Of the 95 patients enrolled, 71 (74.7%) were included in the final analysis. Of these, 40 (56.3%) underwent meniscal surgery and 31 (43.7%) underwent ACLR. After outpatient arthroscopic meniscectomy or repair, the total median postdischarge opioid use was 0.3 pills (oxycodone 5-mg equivalents), with 75% of patients consuming 3.3 or fewer pills (range, 0-19 pills). For ACLR, the median postdischarge consumption was 7 pills (75th percentile, 23.3 pills; range, 0-41 pills). Almost one-third of patients (32.3%) took no opioids after surgery (3 ACLR, 20 meniscus). All meniscus patients and 71% of ACLR patients ceased opioid consumption by postoperative day 7. Conclusion: Opioids may not be necessary in all patients, particularly after meniscal surgery and in comparison with ACLR. For patients requesting opioids for pain relief, reasonable prescription quantities are 5 oxycodone 5-mg pills after arthroscopic meniscal procedures and 20 5-mg pills after ACLR. Slowing the current opioid epidemic and preventing future crises is dependent on refining prescribing habits. Clinicians should strongly consider patient education regarding expected pain as well as pain management strategies.
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Affiliation(s)
- Francis Lovecchio
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Ajay Premkumar
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Tyler Uppstrom
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Jeffrey Stepan
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Brittany Ammerman
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Moira McCarthy
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Beth Shubin Stein
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Andrew Pearle
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Samuel Taylor
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Kanuypria Kumar
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, USA
| | - Todd Albert
- Spine Service, Hospital for Special Surgery, New York, New York, USA
| | - Jo Hannafin
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
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14
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Abstract
STUDY DESIGN Prospective observational study OBJECTIVE.: The aim of this study was to record daily opioid use and pain levels after 1-level lumbar decompression or microdiscectomy. SUMMARY OF BACKGROUND DATA The standardization of opioid-prescribing practices through guidelines can decrease the risk of misuse and lower the number of pills available for diversion in this high-risk patient population. However, there is a paucity of quantitative data on the "minimum necessary amount" of opioid appropriate for post-discharge prescriptions. METHODS At two institutions between September 2017 and 2018, we prospectively enrolled 85 consecutive adult patients who underwent one-level lumbar decompression or microdiscectomy. Patients with a history of opioid dependence were excluded. Daily opioid consumption and pain scores were collected using an automated text-messaging-based platform for 6 weeks or until consumption ceased. Refills during the study period were monitored. Patients were asked for the number of pills left over and the method of disposal. Opioid use was converted to oral morphine equivalents (OMEs). Results are also reported in terms of "pills" (oxycodone 5 mg equivalents) to facilitate clinical applications. Risk factors were compared between patients in the top and bottom half of opioid consumption. RESULTS Total opioid consumption ranged from 0 to 118 pills, with a median consumption of 32 pills (236.3 OME). Seventy-five percent of patients consumed ≤57 pills (431.3 OME). Mean Numeric Rating Scale pain scores declined steadily over the first 2 weeks. By postoperative day 7 half of the study population had ceased taking opioids altogether. Only 22.4% of patients finished their initial prescription, and only 9.4% of patients obtained a refill. CONCLUSION These data may be used to formulate evidence-based opioid prescription guidelines, establish benchmarks, and identify patients at the higher end of the opioid use spectrum. LEVEL OF EVIDENCE 2.
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15
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A Goal-directed Quality Improvement Initiative to Reduce Opioid Prescriptions After Orthopaedic Procedures. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:e109. [PMID: 31773081 PMCID: PMC6860138 DOI: 10.5435/jaaosglobal-d-19-00109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Orthopaedic surgeons are increasingly aware of deleterious effects of the opioid epidemic and the association between overprescription and diversion toward nonmedical opioid use or substance abuse. Opiate prescriptions at the time of hospital discharge have been identified as target for intervention. This study describes the successful outcome of a goal-directed intervention aimed at decreasing opioid overprescription by providing routine feedback to providers regarding their prescribing patterns.
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16
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Premkumar A, Lovecchio FC, Stepan JG, Sculco PK, Jerabek SA, Gonzalez Della Valle A, Mayman DJ, Pearle AD, Alexiades MM, Albert TJ, Cross MB, Haas SB. Characterization of opioid consumption and disposal patterns after total knee arthroplasty. Bone Joint J 2019; 101-B:98-103. [DOI: 10.1302/0301-620x.101b7.bjj-2018-1518.r1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Aims The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA). Patients and Methods In total, 112 patients undergoing surgery with one of eight arthroplasty surgeons at a single specialty hospital were prospectively enrolled. Three patients were excluded for undergoing secondary procedures within six weeks. Daily pain levels and opioid consumption, quantity, and disposal patterns for leftover medications were collected for six weeks following surgery using a text-messaging platform. Results Overall, 103 of 109 patients (94.5%) completed the daily short message service (SMS) surveys. The mean oral morphine equivalents (OME) consumed during the six weeks post-surgery were 639.6 mg (sd 323.7; 20 to 1616) corresponding to 85.3 tablets of 5 mg oxycodone per patient. A total of 66 patients (64.1%) had stopped taking opioids within six weeks of surgery and had the mean equivalent of 18 oxycodone 5 mg tablets remaining. Only 17 patients (25.7%) appropriately disposed of leftover medications. Conclusion These prospectively collected data provide a benchmark for general opioid consumption after uncomplicated primary unilateral TKA. Many patients are prescribed more opioids than they require, and leftover medication is infrequently disposed of appropriately, which increases the risk for illicit diversion. Cite this article: Bone Joint J 2019;101-B(7 Supple C):98–103
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Affiliation(s)
- A. Premkumar
- Hospital for Special Surgery, New York, New York, USA
| | | | - J. G. Stepan
- Hospital for Special Surgery, New York, New York, USA
| | - P. K. Sculco
- Hospital for Special Surgery, New York, New York, USA
| | - S. A. Jerabek
- Hospital for Special Surgery, New York, New York, USA
| | | | - D. J. Mayman
- Hospital for Special Surgery, New York, New York, USA
| | - A. D. Pearle
- Hospital for Special Surgery, New York, New York, USA
| | | | - T. J. Albert
- Hospital for Special Surgery, New York, New York, USA
| | - M. B. Cross
- Hospital for Special Surgery, New York, New York, USA
| | - S. B. Haas
- Hospital for Special Surgery, New York, New York, USA
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17
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Lovecchio F, Premkumar A, Stepan JG, Albert TJ. Fighting Back: Institutional Strategies to Combat the Opioid Epidemic: A Systematic Review. HSS J 2019; 15:66-71. [PMID: 30863235 PMCID: PMC6384220 DOI: 10.1007/s11420-018-09662-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/10/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current research on opioid use within orthopedic surgery has focused on efforts to identify patients at risk for chronic opioid use. Studies addressing prevention of opioid misuse related to orthopedic care are lacking. Evidence-based interventions to reduce the reliance on opioids for post-operative pain relief will be a key component of any comprehensive institutional opioid policy. QUESTIONS/PURPOSES The purpose of this systematic review was to evaluate institutional strategies that reduce opioid administration or consumption after orthopedic surgery. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, a search was conducted of the PubMed database for English-language articles that analyzed interventions by physicians, nurses, pharmacists, physical therapists, or other hospital staff to reduce post-operative opioid use or narcotic prescription amounts after surgery. Studies that contained objective outcome measures (i.e., no expert opinion articles) were selected. Investigations on the effect of pharmacologic adjuvants, cryotherapy, or regional nerve blockades on opioid use were excluded. RESULTS The initial search yielded 6598 titles, of which 13 full-text articles were ultimately selected for inclusion in this systematic review. The review identified two major categories of interventions-patient-focused and provider-focused (e.g., physicians, nurses, physical therapists, pharmacists). Formal patient education programs were most effective in reducing opioid use. On the provider side, prescribing guidelines appear to decrease the overall number of pills prescribed, often without changes in patient satisfaction or requests for refills. CONCLUSIONS Researchers are just beginning to establish the most effective ways for institutions to reduce opioid use and promote responsible post-operative prescribing. Institutional prescribing guidelines, standardized bedside pain-management programs, and formal patient education curriculums are all evidence-based interventions that can achieve these goals. The available research also supports an interprofessional approach in any institutional opioid-reduction strategy.
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Affiliation(s)
- Francis Lovecchio
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Ajay Premkumar
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Jeffrey G. Stepan
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Todd J. Albert
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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18
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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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