Factors Predictive of Prolonged Postoperative Narcotic Usage Following Orthopaedic Surgery

Abstract

Background: The purpose of this comprehensive review was to investigate risk factors associated with prolonged opioid use after orthopaedic procedures. A comprehensive review of the opioid literature may help to better guide preoperative management of expectations as well as opioid-prescribing practices. Methods: A systematic review of all studies pertaining to opioid use in relation to orthopaedic procedures was conducted using the MEDLINE, Embase, and CINAHL databases. Data from studies reporting on postoperative opioid use at various time points were collected. Opioid use and risk of prolonged opioid use were subcategorized by subspecialty, and aggregate data for each category were calculated. Results: There were a total of 1,445 eligible studies, of which 45 met inclusion criteria. Subspecialties included joint arthroplasty, spine, trauma, sports, and hand surgery. A total of 458,993 patients were included, including 353,330 (77%) prolonged postoperative opioid users and 105,663 (23%) non-opioid users. Factors associated with prolonged postoperative opioid use among all evaluated studies included body mass index (BMI) of ≥40 kg/m2 (relative risk [RR], 1.06 to 2.32), prior substance abuse (RR, 1.08 to 3.59), prior use of other medications (RR, 1.01 to 1.46), psychiatric comorbidities (RR, 1.08 to 1.54), and chronic pain conditions including chronic back pain (RR, 1.01 to 10.90), fibromyalgia (RR, 1.01 to 2.30), and migraines (RR, 1.01 to 5.11). Age cohorts associated with a decreased risk of prolonged postoperative opioid use were those ≥31 years of age for hand procedures (RR, 0.47 to 0.94), ≥50 years of age for total hip arthroplasty (RR, 0.70 to 0.80), and ≥70 years of age for total knee arthroplasty (RR, 0.40 to 0.80). Age cohorts associated with an increased risk of prolonged postoperative opioid use were those ≥50 years of age for sports procedures (RR, 1.11 to 2.57) or total shoulder arthroplasty (RR, 1.26 to 1.40) and those ≥70 years of age for spine procedures (RR, 1.61). Identified risk factors for postoperative use were similar across subspecialties. Conclusions: We provide a comprehensive review of the various preoperative and postoperative risk factors associated with prolonged opioid use after elective and nonelective orthopaedic procedures. Increased BMI, prior substance abuse, psychiatric comorbidities, and chronic pain conditions were most commonly associated with prolonged postoperative opioid use. Careful consideration of elective surgical intervention for painful conditions and perioperative identification of risk factors within each patient’s biopsychosocial context will be essential for future modulation of physician opioid-prescribing patterns. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of COVID-19 on opioid use in those awaiting hip and knee arthroplasty: a retrospective cohort study

“…We identified that patients were required to wait longer for their surgery (88-day difference in median wait time from referral to follow-up), and a significantly larger proportion of patients were prescribed opioid-based analgesia (14 percentage points more in the COVID-19 group compared with our historical Controls) preoperatively, despite a lower frequency of opioid use at referral. Given the previously known associations between preoperative opioid use and poorer perioperative surgical outcomes, [9][10][11][12][13][14] urgent attention is required to identify alternative effective non-operative treatment strategies or expedite operative intervention for those awaiting arthroplasty surgery. Increasing use of opioid medication routinely within this healthcare setting may also have larger long-term consequences for public health.…”

“… 8 More specifically within the arthroplasty population, long-term opioid use preoperatively has been associated with increased risk of perioperative complications, 9 10 poorer functional outcome 11 12 and ongoing opioid dependence postoperatively. 13 14 …”

Older, Heavier, Arthritic, Psychiatrically Disordered, and Opioid-Familiar Patients Are at Risk for Opioid Use After Medial Patellofemoral Ligament Reconstruction

“…Across multiple subspecialties in orthopaedic surgery, the literature has consistently demonstrated that preoperative opioid use strongly predicts prolonged opioid demand after surgery. 7,[10][11][12][13][14][15][16][17][18][19][20][21]25,26 Anthony et al 19 conducted a multicenter review of 4,946 ACL reconstructions and found that patients with preoperative prescriptions were 4.06 times (95% CI, relative risk 3.33-4.96) more likely to be refilling prescriptions at 2 months and 5.35 to 7.67 times more likely at all time points between 3 and 12 months after surgery. The majority of patients discontinued opioid use after the first postoperative month, with 10% or less refilling at 2 months and beyond.…”

“…Previous substance use was among the top predictors for adverse opioid-related outcomes, which included previous benzodiazepines, muscle relaxants, opioids, alcohol, cannabis, and cocaine use. Lavoie-Gagne and colleagues 25 performed a systematic review of 45 studies including 458,993 patients across various orthopaedic subspecialties to identify risk factors for prolonged opioid use after surgery. Across all studies, previous substance abuse aside from tobacco and alcohol, use of other medications, psychiatric comorbidities, BMI greater than 40, chronic pain conditions, fibromyalgia, and migraines were all associated with prolonged opioid use after surgery.…”

“… 9 Multiple studies have investigated risk factors leading to prolonged opioid use after common orthopaedic surgeries (e.g., arthritis, psych history, etc.). 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 Identifying predictive factors for prolonged opioid use is crucial for orthopaedic surgeons to tailor pain control for specific patients and practice opioid stewardship.…”