Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty

Wise, Kelsey; McCreary, Dylan L.; Parikh, Harsh R.; Horst, Patrick; Koenig, Karl; Cunningham, Brian P.; Ring, David

doi:10.1016/j.arth.2020.03.001

Cited by 6 publications

(5 citation statements)

References 37 publications

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“…The current evidence regarding the association between age and prolonged opioid use is inconsistent. 2,8,26 Two studies evaluating risk factors associated with prolonged opioid use and opioid prescription filling behavior reported similar findings regarding age as in the current study. 14,27 This can be explained by the fact that older patients may have more comorbidities and pain issues, reflected by its correlation with the Elixhauser comorbidity index score, compared Factors Associated with Prolonged Opioid Use after CMC Arthroplasty Zamri et al…”

Section: Discussionsupporting

confidence: 85%

Factors Associated with Prolonged Opioid Use after CMC Arthroplasty

Zamri

Lans

Jupiter

et al. 2023

Journal of Hand and Microsurgery

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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.

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Section: Discussionsupporting

confidence: 85%

Factors Associated with Prolonged Opioid Use after CMC Arthroplasty

Zamri

Lans

Jupiter

et al. 2023

Journal of Hand and Microsurgery

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“… 8 The common assumption has been that larger initial prescriptions will decrease the burden of patient phone calls and refill requests. 14 However, similar to other nonorthopedic 18 and orthopedic 26 , 37 studies, our results contradict this assumption, suggesting that patients who are given more opiates will request and utilize more opiates. Our findings are similar to prior literature across a range of surgical procedures.…”

Section: Discussionsupporting

confidence: 76%

“…In another study of 1372 opiate-naïve patients undergoing total knee arthroplasty, patients who required a refill initially received a 46.7% larger initial opioid prescription. 37 The mounting evidence that patients who are given more opiates initially will ultimately require more opiates postoperatively highlights the importance of preoperative opioid education, managing patient expectations, and standardizing prescribing practices to minimize the risk of iatrogenic dependence. Furthermore, as this study demonstrates that the quantity of opioids initially prescribed will not reduce the number of required refills, we propose that surgeons should consider prescribing conservatively without undue concern for the burden of refill requests.…”

Section: Discussionmentioning

confidence: 99%

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

et al. 2021

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Introduction Pain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery. Methods The Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months. Results Of the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group ( P < .001). On multivariate analysis, younger age, female gender, and tobacco use, along with the comorbidities of coronary artery disease, clinical depression, diabetes, and rheumatic disease were all found to be predictive factors of prolonged opioid use. Discussion The dose-dependent relationship observed between original opioid prescription data and number of additional refills needed, suggests that initially overprescribing opioids may lead to prolonged dependency. This study also identified several independent risk factors for prolonged opioid use, including younger age, depression, and tobacco use. This study will hopefully help recognize high-risk patient populations and serve as the foundation for future studies into opioid prescription standardization and preoperative opioid education.

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“…31 Regarding prescription strength following TKA, patients given initial prescriptions with higher MME (301) were associated with increased risk of second refill at 30 days compared to those with a lower MME (205.6). 32 Similarly, a study on veterans who received TKA exhibited correlations between high postoperative opioid dose and prolonged opioid use as well as lower postoperative dose and earlier opioid independence. 33 Overall, it is likely that many patients are prescribed more opioids than are needed for adequate pain control, which is associated with an increased risk of prolonged opioid use following TKA.…”

Section: Postoperative Prescription Characteristicsmentioning

confidence: 95%

“…34 SMOKING AND ALCOHOL Among TKA patients, smokers are more likely to fill a second prescription at 30 days and among TKA and THA patients, smokers require an average of 90% more MME postoperatively than nonsmokers. 32,35 Alcohol use is also associated with increased postoperative opioid use in TKA patients. 31,36 One study also demonstrated marijuana use as a significant risk factor for prolonged postoperative opioid use.…”

Section: Postoperative Prescription Characteristicsmentioning

confidence: 99%

The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties

et al. 2022

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Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.

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Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty

Cited by 6 publications

References 37 publications

Factors Associated with Prolonged Opioid Use after CMC Arthroplasty

Factors Associated with Prolonged Opioid Use after CMC Arthroplasty

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties

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