Inpatient and outpatient opioid requirements after total joint replacement are strongly influenced by patient and surgical factors

Abstract

Aims Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty. Methods Outcomes after 92 primary total knee (n = 49) and hip (n = 43) arthroplasties were analyzed. Patients with repeat surgery within 90 days were excluded. Opioid use was recorded while inpatient and 90 days postoperatively. Outcomes included total opioid use, refills, use beyond 90 days, and unplanned clinical encounters for uncontrolled pain. Multivariate modelling determined the effect of surgery, regional nerve block (RNB) or neuraxial anesthesia (NA), and non-opioid medications after adjusting for demographics, ength of stay, and baseline opioid use. Results TKAs had higher daily inpatient opioid use than THAs (in 5 mg oxycodone pill equivalents: median 12.0 vs 7.0; p < 0.001), and greater 90 day use (median 224.0 vs 100.5; p < 0.001). Opioid refills were more likely in TKA (84% vs 33%; p < 0.001). Patient who underwent TKA had higher independent risk of opioid use beyond 90 days than THA (adjusted OR 7.64; 95% SE 1.23 to 47.5; p = 0.01). Inpatient opioid use 24 hours before discharge was the strongest independent predictor of 90-day opioid use (p < 0.001). Surgical procedure, demographics, and baseline opioid use have greater influence on in/outpatient opioid demand than RNB, NA, or non-opioid analgesics. Conclusion Opioid use following TKA and THA is most strongly predicted by surgical and patient factors. TKA was associated with higher postoperative opioid requirements than THA. RNB and NA did not diminish total inpatient or 90-day postoperative opioid consumption. The use of acetaminophen, gabapentin, or NSAIDs did not significantly alter inpatient opioid requirements. Cite this article: Bone Joint Open 2020;1-7:398–404.

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

“…35,37 OTHER Other factors contributing to increased opioid use include specific characteristics of the surgery such as operative time and patient pain in the immediate postoperative period. 24,[42][43][44][45] Cao et al showed that longer operative times were independently associated with increased opioid use, which correlate with the previous findings of Polizer et al 24,43 Increased pain on post-operative day one and increased opioid utilization in the 24-hours before hospital discharge are also independent predictors of prolonged opioid use following TKA. 42,44,45…”

“…24,[42][43][44][45] Cao et al showed that longer operative times were independently associated with increased opioid use, which correlate with the previous findings of Polizer et al 24,43 Increased pain on post-operative day one and increased opioid utilization in the 24-hours before hospital discharge are also independent predictors of prolonged opioid use following TKA. 42,44,45…”

Opioid Use Consequences, Governmental Strategies, and Alternative Pain Control Techniques Following Total Hip Arthroplasties

“…[52][53][54] In addition, younger and unemployed individuals were found to be more likely to need greater opioid quantities in the post-operative period compared to older individuals or those with employment. 55 Additionally, Medicare patients were found to be more likely to demonstrate chronic opioid use in contrast to their non-Medicare counterparts. 56 OTHER Many medical comorbidities afflicting patients undergoing THA are associated with increased post-operative opioid utilization.…”

“…Certain comorbidities that have been linked with increased opioid use after THA include mental health disorders, diabetes, hypertension, chronic pulmonary disease, chronic kidney disease, acquired immunodeficiency syndrome (AIDS), peripheral vascular disease, chronic nonspecific pain, and substance abuse. 51,52,54,55 History of prior hospital complications is also associated with increased post-operative opioid use. 50 In addition, patients who have inferior health statuses pre-operatively, denoted by an ASA score over 2, have been found to have inferior outcomes with regards to chronic opioid use.…”

Reduced Narcotic Utilization in Total Joint Arthroplasty Patients in an Urban Tertiary Care Center

“…Preoperative opioid use is the strongest and most consistent predictor of postoperative opioid use while other factors continue to be debated [ [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] ]. Black race, chronic pulmonary disease, anxiety, substance abuse, and back pain were found in 1 study to be risk factors for increased postoperative opioid use [ 23 ].…”