New persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders. This suggests its use is not due to surgical pain but addressable patient-level predictors. New persistent opioid use represents a common but previously underappreciated surgical complication that warrants increased awareness.

Few studies have assessed postoperative trends in opioid cessation and predictors of persistent opioid use after total knee arthroplasty (TKA) and total hip arthroplasty (THA). Preoperatively 574 TKA and THA patients completed validated, self-report measures of pain, functioning and mood and were longitudinally assessed for 6-months post-surgery. Among patients who were opioid naïve the day of surgery, 8.2% of TKA and 4.3% of THA patients were using opioids at 6 months. In comparison, 53.3% of TKA and 34.7% of THA patients who reported opioid use the day of surgery continued to use opioids at 6 months. Patients taking >60 mg oral morphine equivalents preoperatively had an 80% likelihood of persistent use postoperatively. Day of surgery predictors for 6-month opioid use by opioid naïve patients included greater overall body pain (p=0.002), greater affected joint pain (knee/hip) (p=0.034), and greater catastrophizing (p=0.010). For both opioid naïve and opioid users on day of surgery, decreases in overall body pain from baseline to 6 months were associated with decreased odds of being on opioids at 6 months (aOR=0.72, p=0.050; aOR=0.62, p=0.001); however, change in affected joint pain (knee/hip) was not predictive of opioid use (aOR=0.99, p=0.939; aOR=1.00, p=0.963). In conclusion, many patients taking opioids prior to surgery continue to use opioids after arthroplasty and some opioid naïve patients remained on opioids; however persistent opioid use was not associated with change in joint pain. Given growing concerns about chronic opioid use, the reasons for persistent opioid use and perioperative prescribing of opioids deserve further study.

The comorbidity of pain and depression has been well established in the literature and is associated with a greater burden to the individual and society than either condition alone. The relationship between pain and depression is quite complex and multiple factors must be considered when trying to disentangle the pain-depression link including shared neurobiology, precipitating environmental factors and cognitive influences. This article aims to provide an overview of the leading neurobiological and psychosocial theories that have advanced our understanding of the link between pain and depression. To this end we describe the shared neurobiological mechanisms in the brain thought to explain the overlap and consider psychological processes and how they inform a cognitive behavioral model. The article also provides an overview of the evidence based treatment for comorbid pain and depression.

In this large study of preoperative opioid use that includes patient-reported outcome measures, more than 1 in 4 patients presenting for surgery reported opioid use. These data provide important insights into this complicated patient population that would appear to help guide future preoperative optimization and perioperative opioid-weaning interventions.