Persistent Opioid Use High After Hip or Knee Surgery

Veronica Hackethal, MD

April 26, 2017

One in 14 patients who use opioids before total hip or knee replacement surgery become persistent users during the year after their operation, according to a study published April 19 in Osteoarthritis and Cartilage.

The fraction is "surprisingly large," lead author Brian Bateman, MD, from Harvard Medical School, Boston, Massachusetts, told Medscape Medical News via email.

"Patients who use opioids heavily before the operation have a particularly high risk of staying on them following the surgery, despite the fact that the surgery should improve their joint pain," he said.

Osteoarthritis affects almost one third of individuals aged 65 years and older, with the hips and knee joints most often affected. Surgery can improve pain and function in patients who do not respond to nonsurgical therapy, including exercise, education, physical therapy, steroid injections, and medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Opioids may be used cautiously in patients who cannot take or do not respond to acetaminophen or NSAIDs, according to background information in the article.

Unfortunately, use of prescription opioids has jumped in recent decades. Increasing use among older patients is particularly concerning, given the risk for opioid dependency and withdrawal. Evidence also suggests that taking opioids before hip or knee replacement surgery may actually contribute to increased pain, stiffness, and need for additional surgery.

To look at the problem more closely, Dr Bateman and colleagues used the United HealthCare/Optum Clinformatics Data Mart Database to review commercial insurance inpatient and outpatient claims for 57,545 patients who underwent total hip or knee replacement surgery between January 2004 and December 2013. The patients had a mean age of 61.5 years, and 57.0% were women.

Results showed that 87.1% of the patients in this study used opioids before surgery. Among these, 7.6% used opioids persistently in the year after surgery, with persistent used defined as filling one or more opioid prescription every month during the year after undergoing surgery.

Among heavy preoperative users who took opioids 80% of the time during the 4 or months before surgery (n=3023), 72.1% became persistent users.

Strong predictors of persistent opioid use after surgery included having knee replacement surgery (as opposed to hip replacement), longer hospitalization, discharge to a rehabilitation facility, pattern of preoperative opioid use (longer duration, greater dosage, greater frequency), painful comorbidities (back pain, rheumatoid arthritis, fibromyalgia, migraine), smoking, and benzodiazepine use before surgery (C-statistic, 0.917).

The authors noted several limitations, including the possibility that results may not generalize to patients without insurance, those with different commercial health insurance, or those with public insurance.

To identify patients at risk for persistent opioid use, they advised careful preoperative evaluation and better postoperative pain management, especially in patients with frequent opioid use before surgery.

"Clinicians need to be attentive to this risk, given all of the problems associated with chronic opioid use, and work with patients after their surgery to wean them off opioids. If this is not possible to accomplish, these patients should be referred to a pain specialist who can develop a comprehensive plan for addressing ongoing pain conditions and evaluate the appropriateness of chronic opioid use," Dr Bateman stressed.

One or more authors consults for or reports research grants to their institution from one or more of the following: Lilly, Genentech, Pfizer, Bristol-Myers Squibb, Merck AstraZeneca, Otsuka America, SureScripts, Baxalata, GlaxoSmithKline, and/or Optum.

Osteoarthritis Cartilage. Published online April 19, 2017. Abstract

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