Ingrid Hein

March 04, 2016

ORLANDO, Florida — For patients undergoing total knee arthroplasty, preoperative opioid use is a red flag for postoperative opioid use and surgical complications, according to new research.

If a patient is taking narcotics preoperatively, "they could be at risk for being on opiates much longer and be more likely to have complications," said Robert Westermann, MD, from the Department of Orthopedics at the University of Iowa in Iowa City.

"Narcotic use can be dangerous. We need to understand how much to give and why we're giving it," he told Medscape Medical News. Initiatives that encourage orthopedic surgeons to decrease the use of opioids are needed, he said.

"The United States consumes 99% of the world's supply of hydrocodone and 83% of the world's supply of oxycodone," Dr Westermann reported here at the American Academy of Orthopaedic Surgeons 2016 Annual Meeting. "In other countries, people go home on Tylenol 3," he said.

Dr Westermann and his colleagues identified 112,569 patients who underwent total knee arthroplasty from 2007 to 2014 in the Humana Inc. administrative claims dataset.

Of these patients, 44.0% had no history of opioid use; however, 31.2% filled at least one opioid prescription in the 3 months before surgery, and 24.8% filled at least one prescription more than 3 months before surgery.

More presurgery opioid users than nonusers had filled an opioid prescription at 1-month follow-up (83.2% vs 52.1%), and at 12-month follow-up, the difference was significant (24.0% vs 2.7%).

The researchers identified patient comorbidities and 90-day complication rates using International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes.

They found that patients who filled an opioid prescription in the 3 months before surgery were more likely than nonusers to have medical comorbidities like diabetes kidney or coronary artery disease (average Charlson Comorbidity Index, 3 vs 2; P < .05).

Across the board, 90-day complication rates were higher in presurgery opioid users than in nonusers.

Table. 90-Day Postoperative Complications

Complication Presurgery Opioid Users, % Nonusers, % P Value
Pulmonary embolus 1.75 1.71 .6911
Deep vein thrombosis 4.07 3.86 .1155
Acute myocardial infarction 0.85 0.81 .6051
Respiratory failure 4.75 4.05 <.0001
Catheter-associated urinary tract infection 0.04 0.04 .9056
Pneumonia 2.73 2.37 .0006
Acute renal failure 4.38 3.69 <.0001
Cerebrovascular event 2.44 2.30 .1794
Acute cholecystitis 0.19 0.23 .1327
Infection requiring surgery 1.25 0.70 <.0001
Surgical-site infection 4.00 2.90 <.0001
Revision total knee arthroplasty 0.73 0.41 <.0001


"We hope to do further research to see whether complication rates will come down if opiate users stop taking medication before surgery," said Dr Westermann.

A separate study presented at the meeting did just that. Researchers looked at 41 opioid users who reduced their use by 50% 6 weeks before either a total knee or total hip arthroplasty. These patients were matched with 41 opioid users who did not cut back before surgery and 41 patients who were not using opioids.

The results showed that complication and infection rates during the 90 days after surgery were comparable in the opioid users who cut back and the nonusers.

"We wanted to look at the effect of dose," said David Sing, a clinical research associate at the University of California, San Francisco. "Patients who weaned had higher physical function and better final scores."

In the group that didn't wean, there was a 7.5-fold increase in opioid use after surgery. "That shows us they have a reduced pain tolerance," he told Medscape Medical News.

Sing said they weaned patients by counseling and tapering use every week until they reached their target. It's definitely a modifiable risk that can be managed, and more can be done, he explained. "There are pain specialists out there whose main clientele are opioid-dependent people. They can provide a more holistic approach to addressing addiction."

Most patients expect that when they walk into a physician's office, they'll leave with either a brace or a pain medication prescription.

"It's a hard sell now. Most patients expect that when they walk into a physician's office, they'll leave with either a brace or a pain medication prescription," said John Martell Jr, MD, chief of orthopedic surgery at the VA North Texas Health Care System in Dallas. "Sometimes it's better if they leave with advice instead of that wonder pill," he said.

Currently, the American Academy of Orthopaedic Surgeons recommends the use of nonsteroidal anti-inflammatory drugs for patients with symptomatic osteoarthritis of the knee, but does not offer an opinion on opioid use.

"Opioids do pretty poorly with musculoskeletal pain," said Dr Martell told Medscape Medical News. "Anti-inflammatories actually work better."

One study demonstrated that opioids have a minimal effect on pain and physical function for patients with osteoarthritis, and revealed that evidence of their effectiveness and safety is contradictory (Cochrane Database Syst Rev. 2014;9:CD003115).

But as an orthopedic surgeon, it can be difficult to convince patients, Dr Martell reported. By the time surgeons see patients, primary care providers have often already convinced them that they need pain narcotics.

Traditional methods of dealing with pain are often the best. "Sometimes I think we should just go back to the good old days and tell patients to use ice," he explained.

Dr Westermann and Dr Martell have disclosed no relevant financial relationships.

American Academy of Orthopaedic Surgeons (AAOS) 2016 Annual Meeting: Poster 161. Presented March 1, 2016.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.