Tinker Ready

October 24, 2017

BOSTON — In-hospital opioid use after hip and knee replacement surgeries decreased by one third between 2006 and 2014, according to a study presented here at Anesthesiology 2017 from the American Society of Anesthesiologists on October 21.

Researchers at the University of Massachusetts Medical School in Worcester analyzed data from more than 1.5 million hip and knee replacement surgeries performed at 546 hospitals and included in the national Premier Perspective database.

Among patients who underwent total hip arthroplasty (THA), 27.2% (7896 of 29,010) received opioids alone to manage pain in 2006 compared with only 10.1% (5311 of 52,208) in 2014. Similarly, among those patients undergoing total knee arthroplasty (TKA), 23.3% (14,418 of 61,888) received opioids alone to manage pain in 2006 compared with only 7.2% (7154 of 98,807) in 2014.

The researchers note than 1 million Americans have THA or TKA every year. "Most are prescribed opioids to manage pain as they recover, and about 30% develop chronic pain and continue to use opioids a long time after surgery."

In addition to measuring the number of patients who received only opioids alone, the researchers looked at trends in the use of multimodal therapy. They defined the multimodal approach as opioids and one to three other pain management methods, including peripheral nerve block, acetaminophen, gabapentin/pregabalin, nonsteroidal anti-inflammatories, COX-2 inhibitors, or ketamine.

The researchers reported that in both types of surgeries, multimodal pain control increased dramatically during the study. Slightly more than half of patients with THA and TKA received multimodal care in 2006 (52.4% and 58.5%). By 2014, that number jumped to 92.5% and 97.7%, respectively.

"Not only has the number of opioids we are using in patients decreased substantially, we are also seeing a decrease in the number of patients using only opioids and a huge increase in [the proportion of] patients who are receiving multiple pain modalities," lead author Philipp Gerner, a medical student at the University of Massachusetts Medical School, told Medscape Medical News.

Those findings mean providers are finding ways to reduce pain without opioids.

"It's not that that we're not treating patients and everyone is in pain now, but we've been able to use multimodal pain management to adequately control their pain," Gerner said.

Another trend that emerged from the study was that the likelihood of multimodal pain control is somewhat higher in small and medium hospitals than it is in academic hospitals. Specifically, in hospitals with between 300 and 500 beds, 83% to 84% of patients undergoing THA receive multimodal pain control compared with 80% in larger hospitals (P < .0001). The authors note that they found similar results among patients undergoing TKA.

Gerner said it is unclear what is driving the difference in the two settings. He suggested size may play a role in a hospital's ability to implement change.

Ralf Gebhard, MD, director of regional anesthesia for Jackson Memorial Hospital at the University of Miami Miller School of Medicine in Florida, noted that a limitation of the study is that it does not measure out-of-hospital opioid use.

"It doesn't say much about what is going to happen after the patient is discharged," he said.

Gerner agreed, and noted that the database did not include data on posthospital pain management. "A lot of people think that the postdischarge opioid use is what 'is contributing to the opioid epidemic,' " Gebhard said.

The study also did not look at the amount of drug that was prescribed to each patient; rather, the contribution of this study is to measure what is happening at the hospital level, he said.

The medical community in general, and anesthesiologists specifically, are actively pushing back against the opioid epidemic, he said. The study shows how that is happening during the hospital stay from an anesthesiology perspective.

"We're trying to practice what we preach," Gerner said.

The authors and Dr Gebhard have reported no relevant financial disclosures.

Anesthesiology 2017: Abstract A1069. October 21, 2017.

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