Predictors of chronic prescription opioid use after orthopedic surgery: derivation of a clinical prediction rule

Efficacy of Postoperative Opioid-Sparing Regimens for Hand Surgery: A Systematic Review of Randomized Controlled Trials

PURPOSE

Multiple interventions have been implemented to reduce opioid prescribing in upper extremity surgery. However, few studies have evaluated pain relief and patient satisfaction as related to failure of these protocols. We sought to evaluate the efficacy of limited and nonopioid ("opioid-sparing") regimens for upper extremity surgery as it pertains to patient satisfaction, pain experienced, and need for additional refills/rescue analgesia.

METHODS

We aimed to systematically review randomized controlled trials of opioid-sparing approaches in upper extremity surgery. An initial search of studies evaluating opioid-sparing regimens after upper extremity surgery from the elbow distal yielded 1,320 studies, with nine meeting inclusion criteria. Patient demographics, surgery type, postoperative pain regimen, satisfaction measurements, and number of patients inadequately treated within each study were recorded. Outcomes were assessed using descriptive statistics.

RESULTS

Nine randomized controlled trials with 1,480 patients were included. Six of nine studies (67%) reported superiority or equivalence of pain relief with nonopioid or limited opioid regimens. However, across all studies, 4.2% to 25% of patients were not adequately treated by the opioid-sparing protocols. This includes four of seven studies (57%) assessing number of medication refills or rescue analgesia reporting increased pill consumption, refills, or rescue dosing with limited/nonopioid regimens. Five of six studies (83%) reporting satisfaction outcomes found no difference in satisfaction with pain control, medication strength, and overall surgical experience using opioid-sparing regimens.

CONCLUSIONS

Opioid-sparing regimens provide adequate pain relief for most upper extremity surgery patients. However, a meaningful number of patients on opioid-sparing regimens required greater medication refills and increased use of rescue analgesia. These patients also reported no difference in satisfaction compared with limited/nonopioid regimens.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Opioid prescribing patterns for distal radius fractures in the ambulatory setting: A 10-year retrospective study

OBJECTIVE

Distal radius fractures (DRFs) are one of the most common orthopedic injuries, with most managed in the nonoperative ambulatory setting. The objectives of this study are to examine National Health Center Statistics (NHCS) data for DRF treated in the nonoperative ambulatory setting to identify opioid and nonopioid analgesic prescribing patterns and to determine demographic risk factors for prescription of these medications. Design, setting, patients, and measures: This study is a retrospective analysis of data collected by the NHCS from 2007 to 2016. Utilizing International Classification of Diseases codes, all visits to emergency departments and doctors' offices for DRFs were identified. Variables of interest included demographic data, expected payment source, and prescription of opioid or nonopioid analgesics.

RESULTS

During the study timeframe, 15,572,531 total visits for DRFs were recorded. DRF visits requiring opioid and nonopioid analgesic prescriptions increased over time. Patients aged 45-64 years were significantly more likely to receive an opioid prescription than any other age group (p < 0.05). Opioid prescription was positively correlated with the use of workers' compensation and negatively correlated with patients receiving services under charity care (p < 0.05).

CONCLUSIONS

Prescriptions of both opioid and nonopioid analgesic medications for DRF have been steadily increasing over time in the nonoperative ambulatory setting, with middle-aged adults most likely to receive an opioid prescription. Opioid prescription rates differ significantly between patients utilizing workers' compensation and patients receiving services under charity care, suggesting that socioeconomic factors play a role in prescribing patterns.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

Diagnostic profiles associated with long-term opioid therapy in active duty servicemembers

INTRODUCTION

Over-prescription of opioids has diminished in recent years; however, certain populations remain at high risk. There is a dearth of research evaluating prescription rates using specific multimorbidity patterns.

OBJECTIVE

To identify distinct clinical profiles associated with opioid prescription and evaluate their relative odds of receiving long-term opioid therapy.

DESIGN

Retrospective analysis of the complete military electronic health record. We assessed demographics and 26 physiological, psychological, and pain conditions present during initial opioid prescription. Latent class analysis (LCA) identified unique clinical profiles using diagnostic data. Logistic regression measured the odds of these classes receiving long-term opioid therapy.

SETTING

All electronic health data under the TRICARE network.

PARTICIPANTS

All servicemembers on active duty during fiscal years 2016 through 2019 who filled at least one opioid prescription.

MAIN OUTCOME MEASURES

Number and qualitative characteristics of LCA classes; odds ratios (ORs) from logistic regression. We hypothesized that LCA classes characterized by high-risk contraindications would have significantly higher odds of long-term opioid therapy.

RESULTS

A total of N = 714,446 active duty servicemembers were prescribed an opioid during the study window, with 12,940 (1.8%) receiving long-term opioid therapy. LCA identified five classes: Relatively Healthy (82%); Musculoskeletal Acute Pain and Substance Use Disorders (6%); High Pain, Low Mental Health Burden (9%); Low Pain, High Mental Health Burden (2%), and Multisystem Multimorbid (1%). Logistic regression found that, compared to the Relatively Healthy reference, the Multisystem Multimorbid class, characterized by multiple opioid contraindications, had the highest odds of receiving long-term opioid therapy (OR = 9.24; p < .001; 95% confidence interval [CI]: 8.56, 9.98).

CONCLUSION

Analyses demonstrated that classes with greater multimorbidity at the time of prescription, particularly co-occurring psychiatric and pain disorders, had higher likelihood of long-term opioid therapy. Overall, this study helps identify patients most at risk for long-term opioid therapy and has implications for health care policy and patient care.

Prevalence and predictors of long-term opioid use following orthopaedic surgery in an Australian setting: A multicentre, prospective cohort study

Opioid analgesics prescribed for the management of acute pain following orthopaedic surgery may lead to unintended long-term opioid use and associated patient harms. This study aimed to examine the prevalence of opioid use at 90 days after elective orthopaedic surgery across major city, regional and rural locations in New South Wales, Australia. We conducted a prospective, observational cohort study of patients undergoing elective orthopaedic surgery at five hospitals from major city, regional, rural, public and private settings between April 2017 and February 2020. Data were collected by patient questionnaire at the pre-admission clinic 2-6 weeks before surgery and by telephone call after 90 days following surgery. Of the 361 participants recruited, 54% (195/361) were women and the mean age was 67.7 years (standard deviation 10.1 years). Opioid use at 90 or more days after orthopaedic surgery was reported by 15.8% (57/361; 95% confidence interval (CI) 12.2-20%) of all participants and ranged from 3.5% (2/57) at a major city location to 37.8% (14/37) at an inner regional location. Predictors of long-term postoperative opioid use in the multivariable analysis were surgery performed at an inner regional location (adjusted odds ratio 12.26; 95% CI 2.2-68.24) and outer regional location (adjusted odds ratio 5.46; 95% CI 1.09-27.50) after adjusting for known covariates. Long-term opioid use was reported in over 15% of patients following orthopaedic surgery and appears to be more prevalent in regional locations in Australia.

The Influence of Psychosocial Factors on Hip Surgical Disorders and Outcomes After Hip Arthroscopy: A Systematic Review

PURPOSE

To systematically review the associations between mental health and preoperative or postoperative outcomes of hip arthroscopy for femoroacetabular impingement.

METHODS

The literature search was conducted using the PubMed, EMBASE and PsychINFO databases following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

Nine studies were identified that met the inclusion and exclusion criteria. All studies assessing patient-reported outcomes found significantly lower patient-reported outcomes (modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports-Specific Subscale, and International Hip Outcome Tool scores) related to worse mental health functioning before surgery. Specifically, preoperative Hip Outcome Score-Activities of Daily Living and Hip Outcome Score-Sports-Specific Subscale were significantly greater in control patients than patients in the mental health group by 11.6 points (mean difference; 95% confidence interval 7.58-15.79, P < .001) and 10 points (95% confidence interval 5.14-14.87, P < .001), without significant heterogeneity between studies (I² = 28.59, P = .25; I² = 0, P = .93), respectively. Patients with lower mental health status also had lower rates of achieving a minimal clinically important difference in 5 studies included in this review.

CONCLUSIONS

This systematic review finds consistent evidence supporting the association between negative psychological function and worse preoperative and postoperative outcomes for patients with hip disorders. Understanding both the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy.

LEVEL OF EVIDENCE

IV, systematic review of Level II-IV studies.

Differential patterns of opioid misuse between younger and older adults - a retrospective observational study using data from South Carolina's prescription drug monitoring program

Background: Most research on opioid misuse focuses on younger adults, yet opioid-related mortality has risen fastest among older Americans over age 55.Objectives: To assess whether there are differential patterns of opioid misuse over time between younger and older adults and whether South Carolina's mandatory Prescription Drug Monitoring Program (PDMP) affected opioid misuse differentially between the two groups.Methods: We used South Carolina's Reporting and Identification Prescription Tracking System from 2010 to 2018 to calculate an opioid misuse score for 193,073 patients (sex unknown) using days' supply, morphine milligram equivalents (MME), and the numbers of unique prescribers and dispensaries. Multivariable regression was used to assess differential opioid misuse patterns by age group over time and in response to implementation of South Carolina's mandatory PDMP in 2017.Results: We found that between 2011 and 2018, older adults received 57% (p < .01) more in total MME and 25.4 days more (p < .01) in supply, but received prescriptions from fewer doctors (-0.063 doctors, p < 01) and pharmacies (-0.11 pharmacies, p < 01) per year versus younger adults. However, older adults had lower odds of receiving a high misuse score (OR 0.88, p < .01). After the 2017 legislation, misuse scores fell among younger adults (OR 0.79, p < .01) relative to 2011, but not among older adults.Conclusion: Older adults may misuse opioids differently compared to younger adults. Assessment of policies to reduce opioid misuse should take into account subgroup differences that may be masked at the population level.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty

BACKGROUND

Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines.

AIM

To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA.

METHODS

We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients’ preoperative status using hierarchical Poisson and linear regressions, respectively.

RESULTS

There were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15.

CONCLUSION

All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

Public Perceptions of Opioid Use Following Orthopedic Surgery: A Survey

Background: The United States accounts for the majority of prescription opioids consumed worldwide. Recent literature has focused on opioid prescribing patterns among orthopedic surgeons; however, public and patient expectations about postoperative opioid use remain understudied. Purpose: We sought to explore public perceptions of opioid use after elective orthopedic surgery. Methods: We posted a 32-question survey on Amazon Mechanical Turk (MTurk), an online platform with over 500,000 unique registered users that is a validated tool for collecting survey responses in medical research. The survey asked about attitudes regarding opioid use after elective orthopedic surgery and sociodemographic factors, as well as validated assessments of health literacy and patient engagement. Results: Of 727 respondents who completed surveys, nearly half (46%) said they would prefer nonopioid pain medication after elective orthopedic surgery, although 86% said they would expect to be prescribed opioids for 1 week to 1 month postoperatively. About half said they would expect to be prescribed extra opioid medication in case of unexpected pain following surgery, and 50% reported that they would save their pills to treat future pain. Approximately 63% said they would understand their surgeon's opioid weaning, but over ⅓ said weaning would lead to decreased satisfaction with their surgeon. Roughly ⅔ reported that pain control after surgery would directly affect their opinion of the surgeon. Conclusions: Our survey found that some members of the general public reported expectations regarding postoperative opioid prescribing that could lead to decreased patient satisfaction. These findings suggest the need for further research on the value of preoperative patient education in pain management, on patient expectations of pain control after elective surgery, and on the use of opioids following orthopedic surgery.

Sex Differences in Utilization and Perioperative Outcomes of Arthroscopic Rotator Cuff Repair

Background

As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes.

Methods

Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex.

Results

Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable.

Conclusion

Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

Epidemiology of persistent postoperative opioid use after cardiac surgery: a systematic review and meta-analysis

BACKGROUND

The epidemiology of persistent postoperative opioid use at least 3 months after cardiac surgery is poorly characterised despite its potential public health importance.

METHODS

We searched MEDLINE, Embase, and Google Scholar from inception to December 2021 and included studies reporting the rate and risk factors of persistent postoperative opioid use after cardiac surgery in opioid-naive and opioid-exposed patients. We recorded incidence rates and odds ratios (ORs) with 95% confidence intervals (CIs) for risk factors from individual studies and used random-effects inverse variance modelling to generate pooled estimates.

RESULTS

From 10 studies involving 112 298 patients, the pooled rate of persistent postoperative opioid use in opioid-naive patients was 5.7% (95% CI: 4.2-7.2%). Risk factors included female sex (OR 1.18; 95% CI: 1.09-1.29), smoking (OR 1.34; 95% CI: 1.06-1.69), alcohol use (OR 1.43; 95% CI: 1.17-1.76), congestive cardiac failure (OR 1.17; 95% CI: 1.08-1.27), diabetes mellitus (OR 1.21; 95% CI: 1.07-1.37), chronic lung disease (OR 1.42; 95% CI: 1.16-1.75), chronic kidney disease (OR 1.35; 95% CI: 1.08-1.68), and length of hospital stay (per day) (OR 1.03; 95% CI: 1.02-1.04).

CONCLUSIONS

Persistent postoperative opioid use after cardiac surgery affects at least one in 20 patients. The identification of risk factors, such as female sex, smoking, alcohol use, congestive cardiac failure, diabetes mellitus, chronic lung disease, chronic kidney disease, and length of hospital stay, should help target interventions aimed at decreasing its prevalence.

Patient-specific factors, but neither regional anesthesia nor hip-specific cryotherapy, predict postoperative opioid requirements after hip arthroscopy for femoroacetabular impingement (FAI) syndrome

Background

We sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy.

Methods

104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length.

Results

The average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed.

Conclusion

Patient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system.

Level of evidence

III, retrospective cohort study.

Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure

OBJECTIVE

To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs.

DESIGN

Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders.

RESULTS

A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, P < 0.001; OCA: 30.4% vs. 24.8%, P = 0.032; ACI: 33.7% vs. 26.2%, P = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, P = 0.012; OAT: $5,221 vs. $3,823*, P < 0.001; OCA: $6,973 vs. $3,992*, P < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% (P < 0.001) and 28.0% for OAT patients (P = 0.034). There was no statistical difference for ACI patients (P = 0.654).

CONCLUSION

Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic study.

Patient understanding regarding opioid use in an orthopaedic trauma surgery population: a survey study

BACKGROUND

Prior studies have assessed provider knowledge and factors associated with opioid misuse; similar studies evaluating patient knowledge are lacking. The purpose of this study was to assess the degree of understanding regarding opioid use in orthopaedic trauma patients. We also sought to determine the demographic factors and clinical and personal experiences associated with level of understanding.

METHODS

One hundred and sixty-six adult orthopaedic trauma surgery patients across two clinical sites of an academic institution participated in an internet-based survey (2352 invited, 7.1% response rate). Demographic, clinical, and personal experience variables, as well as perceptions surrounding opioid use were collected. Relationships between patient characteristics and opioid perceptions were identified using univariate and multivariable logistic regressions. Alpha = 0.05.

RESULTS

Excellent recognition (> 85% correct) of common opioids, side effects, withdrawal symptoms, and disposal methods was demonstrated by 29%, 10%, 30%, and 2.4% of patients; poor recognition (< 55%) by 11%, 56%, 33%, and 52% of patients, respectively. Compared with white patients, non-white patients had 7.8 times greater odds (95% confidence interval [CI] 1.9-31) of perceiving addiction discrepancy (p = 0.004). Employed patients with higher education levels were less likely to have excellent understanding of side effects (adjusted odds ratio [aOR] 0.06, 95% CI 0.006-0.56; p = 0.01) and to understand that dependence can occur within 2 weeks (aOR 0.28, 95% CI 0.09-0.86; p = 0.03) than unemployed patients. Patients in the second least disadvantaged ADI quartile were more knowledgeable about side effects (aOR 8.8, 95% CI 1.7-46) and withdrawal symptoms (aOR 2.7, 95% CI 1.0-7.2; p = 0.046) than those in the least disadvantaged quartile. Patients who knew someone who was dependent or overdosed on opioids were less likely to perceive addiction discrepancy (aOR 0.24, 95% CI 0.07-0.76; p = 0.02) as well as more likely to have excellent knowledge of withdrawal symptoms (aOR 2.6, 95% CI 1.1-6.5, p = 0.03) and to understand that dependence can develop within 2 weeks (aOR 3.8, 95% CI 1.5-9.8, p = 0.005).

CONCLUSIONS

Level of understanding regarding opioid use is low among orthopaedic trauma surgery patients. Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history.

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

Purpose

Methods

Results

Conclusion

Level of Evidence

Patient-Centered Decision-making for Postoperative Narcotic-Free Endocrine Surgery: A Randomized Clinical Trial

Importance

Historically, opioid pain medications have been overprescribed following thyroid and parathyroid surgery. Many narcotic prescriptions are incompletely consumed, creating waste and opportunities for abuse.

Objective

To determine whether limiting opioid prescriptions after outpatient thyroid and parathyroid surgery to patients who opt in to narcotic treatment reduces opioid consumption without increasing postoperative pain compared with usual care (routine narcotic prescriptions).

Design, Setting, and Participants

A randomized clinical trial of Postoperative Opt-In Narcotic Treatment (POINT) or routine narcotic prescription (control) was conducted at a single tertiary referral center from June 1 to December 30, 2020. A total of 180 adults undergoing ambulatory cervical endocrine surgery, excluding patients currently receiving opioids, were assessed for eligibility. POINT patients received perioperative pain management counseling and were prescribed opioids only on patient request. Patients reported pain scores (0-10) and medication use through 7 daily postoperative surveys. Logistic regression was used to determine factors associated with opioid consumption.

Interventions

Patients in the POINT group were able to opt in or out of receiving prescriptions for opioid pain medication on discharge. Control patients received routine opioid prescriptions on discharge.

Main Outcomes and Measures

Daily peak pain score through postoperative day 7 was the primary outcome. Noninferiority was defined as a difference less than 2 on an 11-point numeric rating scale from 0 to 10. Analysis was conducted on the evaluable population.

Results

Of the 180 patients assessed for eligibility, the final study cohort comprised 102 patients: 48 randomized to POINT and 54 to control. Of these, 79 patients (77.5%) were women and median age was 52 (interquartile range, 43-62) years. A total of 550 opioid tablets were prescribed to the control group, and 230 tablets were prescribed to the POINT group, in which 23 patients (47.9%) opted in for an opioid prescription. None who opted out subsequently required rescue opioids. In the first postoperative week, 17 POINT patients (35.4% of survey responders in the POINT group) reported consuming opioids compared with 27 (50.0%) control patients (P = .16). Median peak outpatient pain scores were 6 (interquartile range, 4-8) in the control group vs 6 (interquartile range, 5-7) in the POINT group (P = .71). In multivariate analysis, patients with a history of narcotic use were 7.5 times more likely to opt in (95% CI, 1.61-50.11; P = .02) and 4.8 times more likely to consume opioids (95% CI, 1.04-1.52; P = .01). Higher body mass index (odds ratio, 1.11; 95% CI, 1.01-1.23; P = .03) and highest inpatient postoperative pain score (odds ratio, 1.24; 95% CI, 1.04-1.52; P = .02) were also associated with opioid consumption.

Conclusions and Relevance

In this trial, an opt-in strategy for postoperative narcotics reduced opioid prescription without increasing pain after cervical endocrine surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT04710069.

Factors Associated with Prolonged Opioid Use after CMC Arthroplasty

Background Higher rates of prolonged opioid use have been reported in patients who undergo thumb carpometacarpal (CMC) arthroplasty compared with other hand procedures. Therefore, the aim of this study is to identify the risk factors associated with prolonged postoperative opioid use after CMC arthroplasty, along with reporting the number of patients who filled an opioid prescription more than 30 days postoperatively.

Materials and Methods Retrospectively, 563 opioid-naïve patients who underwent CMC arthroplasty were included. A manual chart review was performed to collect patient characteristics, and opioid use was determined based on opioid prescription by a physician. Prolonged opioid use was defined as an opioid prescription at 90 to 180 days postoperatively. A multivariable analysis was performed to identify independent factors associated with an opioid prescription at 90 to 180 days postoperatively. Patients had a median age of 60.4 years (interquartile range [IQR]: 55.5–66.9) and had a median follow-up of 7.6 years (IQR: 4.3–12.0).

Results The rates of postoperative opioid use ranged from 6.2% (53 out of 563 patients) at 30 to 59 days postoperatively to 3.9% (22 out of 563 patients) at 150 to 180 days postoperatively. In total, 17.1% (96 out of 563 patients) received a second opioid prescription more than 30 days following surgery, of which 10.8% (61 out of 563 patients) were between 90 and 180 days postoperatively. Older age, defined as a median of 63 years (IQR: 57.10–69.88) (p = 0.027, odds ratio [OR] = 1.04) and a history of psychiatric disease (p = 0.049, OR = 1.86) were independently associated with prolonged opioid use.

Conclusion A prolonged opioid use rate of roughly 11% was found in opioid-naïve patients who underwent CMC arthroplasty. In patients at risk (older patients or psychiatric history) of prolonged opioid use, careful postoperative pain management is recommended.

Preoperative Opioid Education has No Effect on Opioid Use in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Prospective, Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to determine whether a preoperative video-based opioid education reduced narcotics consumption after arthroscopic rotator cuff repair in opioid-naive patients.

METHODS

This was a single-center randomized controlled trial. Preoperatively, the control group received our institution's standard of care for pain management education, whereas the experimental group watched an educational video on the use of opioids. Patients were discharged with 30 × 5 mg/325 mg oxycodone-acetaminophen prescribed: 1 to 2 tablets every 4 to 6 hours. They were contacted daily and asked to report opioid use and visual analog scale pain. A chart review at 3 months post-op was used to analyze for opioid refills.

RESULTS

A total of 130 patients completed the study (65 control and 65 experimental). No statistically significant differences were noted in patient demographics between groups (P > 0.05). Patients in the education group did not use a statistically significant different number of narcotics than the control group throughout the first postoperative week (14.0 pills experimental versus 13.7 pills control, P = 0.60). No statistically significant differences were noted between groups at follow-regarding the rate of prescription refills (P > 0.05).

CONCLUSION

This study suggests that preoperative video-based opioid education may have no effect on reducing the number of narcotic pills consumed after arthroscopic rotator cuff repair.

CLINICAL RELEVANCE

Data exist to suggest that preoperative video-based opioid education has an effect on postoperative consumption; however, the effect of this education in the setting of already-limited opioid-prescribing is not known.

CLINICALTRIALSGOV IDENTIFIER

NCT04018768.

What are the biopsychosocial risk factors associated with pain in postpartum runners? Development of a clinical decision tool

Background

In 2019, a majority of runners participating in running events were female and 49% were of childbearing age. Studies have reported that women are initiating or returning to running after childbirth with up to 35% reporting pain. There are no studies exploring running-related pain or risk factors for this pain after childbirth in runners. Postpartum runners have a variety of biomechanical, musculoskeletal, and physiologic impairments from which to recover from when returning to high impact sports like running, which could influence initiating or returning to running. Therefore, the purpose of this study was to identify risk factors associated with running-related pain in postpartum runners with and without pain. This study also aimed to understand the compounding effects of multiple associative risk factors by developing a clinical decision tool to identify postpartum runners at higher risk for pain.

Methods

Postpartum runners with at least one child ≤36 months who ran once a week and postpartum runners unable to run because of pain, but identified as runners, were surveyed. Running variables (mileage, time to first postpartum run), postpartum variables (delivery type, breastfeeding, incontinence, sleep, fatigue, depression), and demographic information were collected. Risk factors for running-related pain were analyzed in bivariate regression models. Variables meeting criteria (P<0.15) were entered into a multivariate logistic regression model to create a clinical decision tool. The tool identified compounding factors that increased the probability of having running-related pain after childbirth.

Results

Analyses included 538 postpartum runners; 176 (32.7%) reporting running-related pain. Eleven variables were included in the multivariate model with six retained in the clinical decision tool: runner type-novice (OR 3.51; 95% CI 1.65, 7.48), postpartum accumulated fatigue score of >19 (OR 2.48; 95% CI 1.44, 4.28), previous running injury (OR 1.95; 95% CI 1.31, 2.91), vaginal delivery (OR 1.63; 95% CI 1.06, 2.50), incontinence (OR 1.95; 95% CI 1.31, 2.84) and <6.8 hours of sleep on average per night (OR 1.89; 95% CI 1.28, 2.78). Having ≥ 4 risk factors increased the probability of having running-related pain to 61.2%.

Conclusion

The results of this study provide a deeper understanding of the risk factors for running-related pain in postpartum runners. With this information, clinicians can monitor and educate postpartum runners initiating or returning to running. Education could include details of risk factors, combinations of factors for pain and strategies to mitigate risks. Coaches can adapt running workload accounting for fatigue and sleep fluctuations to optimize recovery and performance. Future longitudinal studies that follow asymptomatic postpartum women returning to running after childbirth over time should be performed to validate these findings.

The opioid epidemic from the acute care hospital front line

Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.

Reduced Opioid Use Among Patients Who Received Liposomal Bupivacaine for ACL Reconstruction

Standard multimodal pain management for anterior cruciate ligament reconstruction typically includes a combination of local anesthetics, nonsteroidal anti-inflammatory drugs, and opioids. Opioids present a substantial risk, and there is a rising number of prescription opioid-related overdoses in the United States. The goal of this study was to evaluate the quantity of opioids prescribed to patients who received liposomal bupivacaine as a component of their multi-modal pain regimen. The electronic medical records of patients who underwent anterior cruciate ligament reconstruction by a single surgeon at an urban hospital during a 2-year period were evaluated. Patients in the case group received liposomal bupivacaine and those in the control group did not. Statistical analysis of the number of pills prescribed and numeric pain rating scale scores was performed with a 2-tailed unequal variance t test. Statistical analysis of opioid prescription refills was performed with a chi-square test. A total of 67 patients were included. The mean number of 5-mg oxycodone tablets prescribed to the case group (9.29±10.29 tablets) was significantly lower (P<.01) compared with the number prescribed to the control group (66.26±37.13 tablets). Patients in the case group also were less likely to require an opioid prescription refill at the first follow-up appointment (P<.01; absolute risk reduction, 50%; number needed to treat, 2). Mean numeric pain rating scale score at 2 weeks was 2.8±2.1 in the case group and 3.8±2.4 in the control group (P=.09). Patients who received liposomal bupivacaine as part of multimodal pain management had significantly fewer opioid prescriptions. Despite the reduction in opioids prescribed, patients in the case group only showed a trend toward a reduction in pain at 2-week follow-up. [Orthopedics. 2021;44(2):e229-e235.].

Factors Predictive of Prolonged Postoperative Narcotic Usage Following Orthopaedic Surgery

BACKGROUND

The purpose of this comprehensive review was to investigate risk factors associated with prolonged opioid use after orthopaedic procedures. A comprehensive review of the opioid literature may help to better guide preoperative management of expectations as well as opioid-prescribing practices.

METHODS

A systematic review of all studies pertaining to opioid use in relation to orthopaedic procedures was conducted using the MEDLINE, Embase, and CINAHL databases. Data from studies reporting on postoperative opioid use at various time points were collected. Opioid use and risk of prolonged opioid use were subcategorized by subspecialty, and aggregate data for each category were calculated.

RESULTS

There were a total of 1,445 eligible studies, of which 45 met inclusion criteria. Subspecialties included joint arthroplasty, spine, trauma, sports, and hand surgery. A total of 458,993 patients were included, including 353,330 (77%) prolonged postoperative opioid users and 105,663 (23%) non-opioid users. Factors associated with prolonged postoperative opioid use among all evaluated studies included body mass index (BMI) of ≥40 kg/m (relative risk [RR], 1.06 to 2.32), prior substance abuse (RR, 1.08 to 3.59), prior use of other medications (RR, 1.01 to 1.46), psychiatric comorbidities (RR, 1.08 to 1.54), and chronic pain conditions including chronic back pain (RR, 1.01 to 10.90), fibromyalgia (RR, 1.01 to 2.30), and migraines (RR, 1.01 to 5.11). Age cohorts associated with a decreased risk of prolonged postoperative opioid use were those ≥31 years of age for hand procedures (RR, 0.47 to 0.94), ≥50 years of age for total hip arthroplasty (RR, 0.70 to 0.80), and ≥70 years of age for total knee arthroplasty (RR, 0.40 to 0.80). Age cohorts associated with an increased risk of prolonged postoperative opioid use were those ≥50 years of age for sports procedures (RR, 1.11 to 2.57) or total shoulder arthroplasty (RR, 1.26 to 1.40) and those ≥70 years of age for spine procedures (RR, 1.61). Identified risk factors for postoperative use were similar across subspecialties.

CONCLUSIONS

We provide a comprehensive review of the various preoperative and postoperative risk factors associated with prolonged opioid use after elective and nonelective orthopaedic procedures. Increased BMI, prior substance abuse, psychiatric comorbidities, and chronic pain conditions were most commonly associated with prolonged postoperative opioid use. Careful consideration of elective surgical intervention for painful conditions and perioperative identification of risk factors within each patient's biopsychosocial context will be essential for future modulation of physician opioid-prescribing patterns.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Opioid Requirement following Arthroscopic Knee Surgery: Are There Predictive Factors Associated with Long-Term Use

The purpose of this study is to identify patterns of postoperative narcotic use and determine the impact of psychosocial and perioperative factors on postoperative opioid consumption following arthroscopic knee surgery. Fifty consecutive patients undergoing arthroscopic knee surgery were prospectively enrolled. Patients were contacted via telephone at 1 week postoperatively to report their pain level and opioid consumption. The patient was contacted again at 2 weeks, 4 weeks, and 90 days as necessary until opioid cessation, at which time the patient's plan for unused pills was inquired. Opioid consumption was compared using t-tests and one-way analysis of variance for demographic and surgical factors. Linear regression was used to determine whether the Pain Catastrophizing Scale (PCS), Resilience Scale (RS-11), International Knee Documentation Committee questionnaire, or patient-reported pain at 1 week predicted higher opioid consumption. The average morphine equivalent dose of opioid consumption was 142 mg. Sixty-four percent consumed less than 100 mg, and 68% discontinued opioid use by 1 week postoperatively. Seventy-four percent reported surplus pills, and 49% of those patients plans for pill disposal. Factors associated with higher consumption included undergoing a major procedure, having a regional anesthesia block, and higher area deprivation index score (p < 0.05). Higher PCS scores and reported average pain level at 1 week were predictive of higher opioid consumption (p < 0.05). In conclusion, a majority of patients undergoing outpatient knee surgery did not require the entirety of their narcotic prescription. The majority of patients consumed less than 100 mg of morphine equivalents and discontinued opioid use by 1 week postoperatively. Ligament reconstruction, living in an area with a higher index of deprivation, and higher score on the PCS were associated with greater opioid consumption. Overall, patient knowledge regarding opioid disposal was poor, and patients would likely benefit from additional education prior to surgery.

Comparison of opioid prescribing upon hospital discharge in patients receiving tapentadol versus oxycodone following orthopaedic surgery

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.

[Role of B vitamins, thiamine, pyridoxine, and cyanocobalamin in back pain and other musculoskeletal conditions: a narrative review]

Low back pain, as well as other musculoskeletal disorders (neck pain, osteoarthritis, etc.), are a very frequent cause of consultation both in primary care and in other hospital specialties and are usually associated with high functional and work disability. Acute low back pain can present different nociceptive, neuropathic and nonciplastic components, which leads to consider it as a mixed type pain. The importance of the concept of mixed pain is due to the fact that the symptomatic relief of these pathologies requires a multimodal therapeutic approach to various pharmacological targets. The antinociceptive role of the B vitamin complex has been recognized for several decades, specifically the combination of Thiamine, Pyridoxine and Cyanocobalamin (TPC). Likewise, there is accumulated evidence that indicates an adjuvant analgesic action in low back pain. The aim of the present review is to present the existing evidence and the latest findings on the therapeutic effects of the TPC combination in low back pain. Likewise, some of the most relevant mechanisms of action involved that can explain these effects are analyzed. The reviewed evidence indicates that the combined use of PCT has an adjuvant analgesic effect in mixed pain, specifically in low back pain and other musculoskeletal disorders with nociceptive and neuropathic components. This effect can be explained by an anti-inflammatory, antinociceptive, neuroprotective and neuromodulatory action of the TPC combination on the descending pain system.

Do Narcotic Use, Physical Therapy Location, or Payer Type Predict Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction?

BACKGROUND

Opioid use and public insurance have been correlated with worse outcomes in a number of orthopaedic surgeries. These factors have not been investigated with anterior cruciate ligament reconstruction (ACLR).

PURPOSE/HYPOTHESIS

To evaluate if narcotic use, physical therapy location, and insurance type are predictors of patient-reported outcomes after ACLR. It was hypothesized that at 1 year postsurgically, increased postoperative narcotic use would be associated with worse outcomes, physical therapy obtained within the authors' integrated health care system would lead to better outcomes, and public insurance would lead to worse outcomes and athletic activity.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

All patients undergoing unilateral, primary ACLR between January 2015 and February 2016 at a large health system were enrolled in a standard-of-care prospective cohort. Knee injury and Osteoarthritis Score (KOOS) and the Hospital for Special Surgery Pediatric-Functional Activity Brief Scale (HSS Pedi-FABS) were collected before surgery and at 1 year postoperatively. Concomitant knee pathology was assessed arthroscopically and electronically captured. Patient records were analyzed to determine physical therapy location, insurance status, and narcotic use. Multivariable regression analyses were used to identify significant predictors of the KOOS and HSS Pedi-FABS score.

RESULTS

A total of 258 patients were included in the analysis (mean age, 25.8; 51.2% women). In multivariable regression analysis, narcotic use, physical therapy location, and insurance type were not independent predictors of any KOOS subscales. Public insurance was associated with a lower HSS Pedi-FABS score (-4.551, P = .047) in multivariable analysis. Narcotic use or physical therapy location was not associated with the HSS Pedi-FABS score.

CONCLUSION

Increased narcotic use surrounding surgery, physical therapy location within the authors' health care system, and public versus private insurance were not associated with disease-specific KOOS subscale scores. Patients with public insurance had worse HSS Pedi-FABS activity scores compared with patients with private insurance, but neither narcotic use nor physical therapy location was associated with activity scores. Physical therapy location did not influence outcomes, suggesting that patients be given a choice in the location they received physical therapy (as long as a standardized protocol is followed) to maximize compliance.

Persistent opioid use and opioid-related harm after hospital admissions for surgery and trauma in New Zealand: a population-based cohort study

INTRODUCTION

Opioid use has increased globally for the management of chronic non-cancer-related pain. There are concerns regarding the misuse of opioids leading to persistent opioid use and subsequent hospitalisation and deaths in developed countries. Hospital admissions related to surgery or trauma have been identified as contributing to the increasing opioid use internationally. There are minimal data on persistent opioid use and opioid-related harm in New Zealand (NZ), and how hospital admission for surgery or trauma contributes to this. We aim to describe rates and identify predictors of persistent opioid use among opioid-naïve individuals following hospital discharge for surgery or trauma.

METHODS AND ANALYSIS

This is a population-based, retrospective cohort study using linked data from national health administrative databases for opioid-naïve patients who have had surgery or trauma in NZ between January 2006 and December 2019. Linked data will be used to identify variables of interest including all types of hospital surgeries in NZ, all trauma hospital admissions, opioid dispensing, comorbidities and sociodemographic variables. The primary outcome of this study will be the prevalence of persistent opioid use. Secondary outcomes will include mortality, opioid-related harms and hospitalisation. We will compare the secondary outcomes between persistent and non-persistent opioid user groups. To compute rates, we will divide the total number of outcome events by total follow-up time. Multivariable logistic regression will be used to identify predictors of persistent opioid use. Multivariable Cox regression models will be used to estimate the risk of opioid-related harms and hospitalisation as well as all-cause mortality among the study cohort in a year following hospital discharge for surgery or trauma.

ETHICS AND DISSEMINATION

This study has been approved by the Auckland Health Research Ethics Committee (AHREC- AH1159). Results will be reported in accordance with the Reporting of studies Conducted using Observational Routinely collected health data statement (RECORD).

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

Aims

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

Methods

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

Results

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

Conclusion

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

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

Perioperative Opioid Use Predicts Postoperative Opioid Use and Inferior Outcomes After Shoulder Arthroscopy

PURPOSE

The purpose of this study is to define the impact of preoperative opioid use on postoperative opioid use, patient-reported outcomes, and revision rates in a cohort of patients receiving arthroscopic shoulder surgery.

METHODS

Patients who underwent shoulder arthroscopy were identified from an institutional database. Inclusion criteria were completion of preoperative and postoperative patient-reported outcome measures (PROMs) at 1-year follow-up and completion of a questionnaire on use of opioids and number of pills per day. Outcomes assessed included postoperative PROM scores, postoperative opioid use, persistent pain, and achievement of the patient acceptable symptomatic state. A matched cohort analysis was performed to evaluate the impact of opioid use on achievement of postoperative outcomes, whereas a multivariate regression was performed to determine additional risk factors. Receiver operating characteristic curves were used to establish threshold values in oral morphine equivalents (OMEs) that predicted each outcome.

RESULTS

A total of 184 (16.3%) patients were included in the opioid use (OU) group and 1,058 in the no opioid use (NOU) group. The OU and NOU groups showed statistically significant differences in both preoperative and postoperative scores across all PROMs (P < .001). Multivariate logistic regression identified preoperative opioid use as a significant predictor of reduced achievement of the patient acceptable symptomatic state (odds ratio [OR], 0.69, 95% confidence interval [CI], 0.29-0.83, P = .008), increased likelihood of endorsing persistent pain (OR, 1.73, 95% CI, 1.17-2.56, P = .006), and increased opioid use at 1 year (OR, 21.3, 95% CI, 12.2-37.2, P < .001). Consuming a high dosage during the perioperative period increased risk of revision surgery (OR, 8.59, 95% CI, 2.12-34.78, P < .003). Results were confirmed by matched cohort analysis. Receiver operating characteristic analysis found that total OME >1430 mg/d in the perioperative period (area under the curve, 0.76) and perioperative daily OME >32.5 predicted postoperative opioid consumption (area under the curve, 0.79).

CONCLUSIONS

Patients with a history of preoperative opioid use can achieve significant improvements in patient-reported outcomes after arthroscopic shoulder surgery. However, preoperative opioid use negatively impacts patients' level of satisfaction and is a significant predictor of pain and continued opioid usage.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Risk of Prior Opioid Exposure on Future Opioid Use and Comorbidities in Individuals With Non-Acute Musculoskeletal Knee Pain

Objectives

Due to their potentially deleterious effects, minimizing the use of opioids for musculoskeletal pain is a priority for healthcare systems. The objective of this study was to examine the risk of future opioid prescription use based on prior opioid use within a non-surgical cohort with musculoskeletal knee pain. We also examined the risk of pre-existing comorbidities on future opioid use, and the risk of prior opioid use on future comorbidities (sleep, mental health, cardiometabolic disorders).

Methods

Data came from the Military Health System Data Repository for 80 290 consecutive beneficiaries with an initial episode of care for patellofemoral pain from January 1, 2010 through December 31, 2011. Risk was calculated using 2 × 2 tables based on pre- and post-opioid utilization and comorbid diagnosis. Risk ratios, relative and absolute risk increases, and numbers needed to harm were calculated, all with 95% confidence intervals.

Results

Prior opioid use resulted in a risk ratio of 18.0 (95 CI 17.1, 19.0) and an absolute risk increase of 61.6% for future opioid use (numbers needed to harm = 2). The presence of all comorbidities (except cardiometabolic syndrome) were associated with a significant relative risk for future opioid use (RR range 1.2-1.5), but the absolute risk increase was trivial (range 0.7%-2.2%). The relative risk for a chronic pain diagnosis, traumatic brain injury/concussion, insomnia, depression, and PTSD were all significantly higher in those with prior opioid use (1.3-1.6), but absolute risk increase was minimal (1.1%-6.5%).

Discussion

Prior opioid use was a strong risk factor for future opioid use in non-surgical patients with knee pain. These findings show that history of prior opioid use is important when assessing the risk of future opioid use, whereas prior comorbidities may not be as important. Opioid history assessment should be standard practice for all patients with patellofemoral pain in whom an opioid prescription is considered.

Differences in Pain, Opioid Use, and Function Following Unicompartmental Knee Arthroplasty compared to Total Knee Arthroplasty

BACKGROUND

We sought to determine if immediate postsurgical pain, opioid use, and clinical function differed between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA).

METHODS

A single-institution database was utilized to identify patients who underwent elective total joint arthroplasty between 2016 and 2019.

RESULTS

In total, 6616 patients were identified: 98.20% TKA (6497) and 1.80% (119) UKA. UKA patients were younger, had lower body mass index, and more often male than the TKA cohort. Aggregate opioid consumption (75.94 morphine milligram equivalents vs 136.5 morphine milligram equivalents; P < .001) along with the first 24-hour and 48-hour usage was significantly less for UKA as compared to TKA. Similarly, pain scores (1.98 vs 2.58; P < .001) were lower for UKA while Activity Measure for Post-Acute Care mobilization scores were higher (21.02 vs 18.76; P < .001). UKA patients were able to be discharged home on the day of surgery 37% of the time as compared to 2.45% of TKA patients (P < .0001). Notably, when comparing UKA and TKA patients who were discharged home on the day of surgery, no differences regarding pain scores, opioid utilization, or mobilization were observed.

CONCLUSION

UKA patients are younger, have lower body mass index and American Society of Anesthesiologists scores, and more often male than TKA patients. UKA patients had significantly shorter length of stay than TKA patients and were discharged home more often than TKA patients, on both the day of surgery and following hospital admission. Most notably, UKA patients reported lower pain scores and were found to require 45% lower opioid medication in the immediate postsurgical period than TKA patients. Surprisingly, UKA and TKA patients discharged on the day of surgery did not differ in terms of pain scores, opioid utilization, or mobilization, suggesting that our rapid rehabilitation UKA protocols can be successfully translated to outpatient TKAs with similar outcomes.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Do Socioeconomic Disparities Exist in Postoperative Opioid Prescription and Consumption?

BACKGROUND

Since 1999, >200 000 people in the United States have died from a prescription opioid overdose. Lower socioeconomic status (SES) is one important risk factor. This study investigates socioeconomic disparities in postoperative opioid prescription and consumption.

METHODS

September 2018-April 2019, 128 patients were surveyed postoperatively regarding opioid consumption. The neighborhood disadvantage was calculated using area deprivation index (ADI). The top 3 quartiles were "high SES" and the bottom quartile "low SES."

RESULTS

The study population included 96 high SES patients, median ADI 6 (2-12.3) and 32 low SES, median ADI 94.5 (81.3-97.3). For both, median Oxycodone 5 mg prescribed was 20 pills. 29.2% of high SES consumed 0 pills, 40.6% consumed 1-9 pills, and 27.1% consumed 10+ pills. 25.0% of low SES consumed 0 pills, 46.9% consumed 1-9 pills, and 18.8% consumed 10+ pills. No significant difference in opioid prescription (P = .792) or consumption (P = .508) between SES groups.

DISCUSSION

Patients of all SES are prescribed and consumed opioids in similar patterns with no significant difference in postoperative pain following ambulatory surgery.

The Effect of Psychological Impairment on Outcomes in Patients With Prearthritic Hip Disorders: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have suggested that mental health disorders negatively affect postoperative outcomes in patients with femoroacetabular impingement (FAI). However, the outcome measures reported and the effect sizes have varied. Furthermore, it is unknown whether similar effects are present in young adults with other hip disorders such as acetabular dysplasia.

PURPOSE

To synthesize current evidence regarding the effect of baseline psychological impairment on postintervention outcomes in patients with prearthritic hip disorders.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

In February 2019, the Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov databases were searched for longitudinal studies that evaluated the effect of baseline psychological impairment (such as depression or anxiety) on a postintervention clinical outcome in patients with prearthritic hip disorders including FAI, acetabular dysplasia, and/or acetabular labral tears. Descriptive measures of study quality and bias were recorded, and studies that reported statistically comparable outcomes were analyzed in meta-analyses through use of random effects models.

RESULTS

We identified 12 eligible studies, all of which specifically evaluated patients with FAI after hip arthroscopy. No eligible studies described patients with acetabular dysplasia. Of the included studies, 8 studies reported odds ratios (ORs). The other 4 studies reported mean postoperative scores on patient-reported outcome measures (PROMs), all of which were scored from 0 to 100, with higher numbers being favorable. Patients with psychological impairment were less likely to achieve a favorable outcome after arthroscopy (OR, 0.74; 95% CI, 0.62 to 0.88; P < .001), and they reported worse postoperative PROM scores compared with nonimpaired patients (weighted mean difference, -20.2 points; 95% CI, -32.9 to -7.5; P < .001).

CONCLUSION

Baseline psychological impairment is associated with clinically significantly worse outcomes in patients with femoroacetabular impingement who undergo hip arthroscopy. More standardized reporting would facilitate improved understanding of this important, potentially modifiable risk factor.

REGISTRATION

CRD42019124836 (PROSPERO).

Navigating the Intersection Between Persistent Pain and the Opioid Crisis: Population Health Perspectives for Physical Therapy

The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapist practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts could provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as providing actionable suggestions for physical therapists to help develop and implement upstream interventions that could reduce the impact of OUD in their communities.

Patient and clinician incentives and barriers for opioid use for musculoskeletal disorders a qualitative study on opioid use in musculoskeletal setting

Introduction

Strategies for pain alleviation have relied heavily on opioids in the recent decades. One consequence is a crisis of opioid misuse, overdose, and overdose related death. This study sought patient and clinician incentives and barriers to the use of opioids in musculoskeletal illness.

Methods

In this qualitative study, twenty-eight patients and eight clinicians participated in a semi-structured interview seeking incentives and barriers for opioid use and prescription in musculoskeletal illness. Interviews were conducted by a trained qualitative interviewer. The interview data were transcribed and analyzed using a thematic analysis framework.

Results

Patient incentives for opioid use included doctor's orders, opioids being the only effective way to alleviate pain, alleviating symptoms of depression and anxiety, being able to keep a job, and lower cost of opioids relative to alternative treatment options. Patient barriers included associated risks (side effects, addiction) and wanting to control pain intensity. Clinician incentives for prescribing opioids included adequate pain alleviation, patient satisfaction, relatively inexpensive costs of opioids, convenience and doing what was taught by the clinician's superior. Lacking time and resources to adequately inform patients on appropriate opioid use and alternative treatments, likely results in more opioid prescribing than arguably necessary. Barriers for opioid prescribing included specific patient characteristics (psychiatric background, history of opioid misuse) and illness characteristics (nature of the injury, medical contra-indications).

Conclusion

Patients feel that opioids should be used with caution. Clinicians in this study reported a tendency to default to opioids out of habit and convenience. Both patients and clinicians were aware that opioids are often misused to treat emotional pain.

Study of variations in inpatient opioid consumption after total shoulder arthroplasty: influence of patient- and surgeon-related factors

BACKGROUND

The aims of this study were to examine variances in inpatient opioid consumption after total shoulder arthroplasty (TSA) and to determine factors influencing inpatient opioid utilization.

METHODS

The sample included patients undergoing elective TSA at a tertiary-level institution between January 2016 and April 2018. Opioid consumption during the inpatient stay was converted into morphine milligram equivalents (MMEs), accounting for dosage and route of administration. The MMEs were calculated per patient encounter and used to calculate mean opioid consumption. Bivariate linear regression analysis was performed to assess the impact of patient-related factors and surgery-related factors on inpatient opioid consumption.

RESULTS

Altogether 20 surgeons performed 622 TSAs. The average opioid dose per encounter was 47.4 ± 65.7 MME/d. MMEs prescribed varied significantly among surgeon providers (P < .01). Pre-existing psychiatric disorders (P = .00012), preoperative opioid use (P = .0013), highest quartile of median household income (P = .048), current-smoker status (P < .001), age < 60 years (P < .01), and general anesthesia (vs. regional anesthesia, P = .005) were associated with significant inpatient opioid consumption after TSA. Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences.

CONCLUSION

There is considerable variation in inpatient opioid consumption after TSA at the same institution. Knowledge of modifiable and nonmodifiable risk factors that increase inpatient opioid consumption will help to optimize multimodal analgesia protocols for TSA.

Utility of catastrophizing, body symptom diagram score and history of opioid use to predict future health care utilization after a primary care visit for musculoskeletal pain

BACKGROUND

Self-report information about pain and pain beliefs are often collected during initial consultation for musculoskeletal pain. These data may provide utility beyond the initial encounter, helping provide further insight into prognosis and long-term interactions of the patient with the health system.

OBJECTIVE

The aim of this study was to determine if pain catastrophizing and pain-related body symptoms can predict future health care utilization.

METHODS

This was a longitudinal cohort study. Baseline data were collected after receiving initial care for a musculoskeletal disorder in a multidisciplinary clinic within a large military hospital. Subjects completed the Pain Catastrophizing Scale, a region-specific disability measure, numeric pain rating scale and a body symptom diagram. Health care utilization data for 1 year prior and after the visit were extracted from the Military Health System Data Repository. Multivariable regression models appropriate for skewed and count data were developed to predict (i) musculoskeletal-specific medical visits, (ii) 12-month opioid use, (iii) musculoskeletal-specific medical costs and (iv) total medical costs. We investigated whether a pain catastrophizing × body symptom diagram interaction improved prediction, and developed separate models for opioid-naïve individuals and those with a history of opioid use in an exploratory analysis.

RESULTS

Pain catastrophizing but not body symptom diagram was a significant predictor of musculoskeletal visits, musculoskeletal costs and total medical costs. Exploratory analyses suggest these relationships are most robust for patients with a history of opioid use.

CONCLUSIONS

Pain catastrophizing can identify risk of high health care utilization and costs, even after controlling for common clinical variables. Addressing pain catastrophizing in the primary care setting may help to mitigate future health care utilization and costs, while improving clinical outcomes. These results provide direction for future validation studies in larger and more traditional primary care settings.

New Long-Term Opioid Prescription-Filling Behavior Arising in the 15 Months After Orthopaedic Surgery

BACKGROUND

The opioid crisis is a well-known public health issue. The risk of new long-term opioid prescription-filling behavior has been investigated after certain spinal procedures and total knee and hip arthroplasty. However, this has not been examined after many other common orthopaedic procedures. The purpose of this study was to determine the rates of long-term opioid prescription-filling behavior after common orthopaedic surgical procedures in patients who were not taking opioids preoperatively.

METHODS

This study utilized the Virginia All-Payer Claims Database (APCD), an insurance claims database with data from 3.7 to 4 million patients per year. Patients who underwent orthopaedic procedures and who had not filled an opioid prescription in the time period from 2 weeks to 1 year preceding the surgical procedure were selected for evaluation in our study. The percentage of these patients who then filled at least 10 prescriptions or a 120-day supply of opioids in the time period from 90 to 455 days following the surgical procedure was calculated for the 50 most commonly billed orthopaedic surgical procedures.

RESULTS

The rate of long-term opioid prescription-filling behavior in patients who were not taking opioids preoperatively for the 50 most common orthopaedic procedures was 5.3% (95% confidence interval, 5.1% to 5.5%). The highest rates were observed after spinal procedures. The lowest rates were seen after anterior cruciate ligament (ACL) reconstruction. Revision surgical procedures were found to have a significantly higher rate than primary procedures (p < 0.05). The rate was also related to increasing case complexity.

CONCLUSIONS

New long-term opioid prescription-filling behavior is common after orthopaedic surgical procedures in patients who were not taking opioids preoperatively. Risk factors include spine surgery, revision surgery, and cases with increased complexity. Orthopaedic surgeons need to be aware of this risk.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for opioid use after total shoulder arthroplasty

HYPOTHESIS

The purpose was to assess opioid use before and after anatomic and reverse total shoulder arthroplasty (TSA) and determine patient factors associated with prolonged postoperative opioid use.

METHODS

Patients undergoing primary TSA (anatomic or reverse) were identified within the Humana database from 2007 to 2015. Patients were categorized as opioid-naive patients who did not fill a prescription prior to surgery or those who filled opioid prescriptions within 3 months preoperatively (OU); the OU cohort was subdivided into those filling opioid prescriptions within 1 month preoperatively and those filling opioid prescriptions between 1 and 3 months preoperatively. The incidence of opioid use was evaluated preoperatively and longitudinally tracked for each cohort. Multivariate analysis was used to identify factors associated with opioid use at 12 months after surgery, with statistical significance defined as P < .05.

RESULTS

Overall, 12,038 patients (5180 in OU cohort, 43%) underwent primary TSA during the study period. Opioid use declined after the first postoperative month; however, the incidence of opioid use was significantly higher in the OU cohort than in the opioid-naive cohort at 1 year (31.4% vs. 3.1%, P < .0001). Subgroup analysis revealed a similar decline in postoperative opioid use for anatomic and reverse TSA (P < .0001 for both). Multivariate analysis identified chronic preoperative opioid use (ie, filling an opioid prescription between 1 and 3 months prior to surgery) as the strongest risk factor for opioid use at 12 months after anatomic and reverse TSA (P < .0001).

CONCLUSION

More than 40% of patients undergoing TSA received opioid medications within 3 months before surgery. Preoperative opioid use, age younger than 65 years, and fibromyalgia were independent risk factors for opioid use 1 year following anatomic and reverse TSA. Chronic preoperative opioid use conferred the highest risk of prolonged postoperative opioid use.

Predicting Opioid Use, Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability?

This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident, and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (ie, body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale, and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received. PERSPECTIVE: This article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.