Opioid Use After Discharge Following Primary Unilateral Total Knee Arthroplasty: How Much Are We Over-Prescribing?

doi:10.1016/j.arth.2020.01.078

The Journal of Arthroplasty

Volume 35, Issue 6, Supplement, June 2020, Pages S158-S162

https://doi.org/10.1016/j.arth.2020.01.078 Get rights and content

Abstract

Background

The opioid crisis pressures orthopedic surgeons to reduce the amount of narcotics prescribed for post-operative pain management. This study sought to quantify post-operative opioid use after hospital discharge for primary unilateral total knee arthroplasty (TKA) patients.

Methods

A prospective cohort of primary unilateral TKA patients performed by one of 5 senior fellowship-trained arthroplasty surgeons were enrolled at a single institution. Detailed pain journals tracked all prescriptions and over-the-counter pain medications, quantities, frequencies, and visual analog scale pain scores. Narcotic and narcotic-like pain medications were converted to morphine milligram equivalents (MME). Statistical analysis was performed using Student’s t-test with α < 0.05.

Results

Data from 89 subjects were analyzed; the average visual analog scale pain score was 6.92 while taking narcotics. The average number of days taking narcotics was 16.8 days. The distribution of days taking narcotics was right shifted with 52.8% of patients off narcotics after 2 week, and 74.2% off by 3 weeks post-op. The average MME prescribed was significantly greater than MME taken (866.6 vs 428.2, P < .0001). The average number of narcotic pills prescribed was significantly greater than narcotic pills taken (105.1 vs 52.0, P < .0001). The average excess narcotic pills prescribed per patient was 53.1 pills. About 48.3% took fewer than 40 narcotic pills; 75.3% took fewer than 75 narcotic pills. About 3.4% did not require any narcotics; 40.5% required a refill of narcotics. Also, 9.0% went home the day of surgery.

Conclusion

Significantly more narcotics were prescribed than were taken in the post-operative period following TKA with an average 53.1 excess narcotic pills per patient. Adjusting prescribing patterns to match patient narcotic usage could reduce the excess narcotic pills following TKA.

Section snippets

Materials and Methods

Institutional Review Board approval was obtained prior to study initiation. A prospective cohort of primary unilateral TKA patients performed by one of 5 senior fellowship-trained arthroplasty surgeons were enrolled at a single institution for 1 year from December 1, 2017 to December 1, 2018. Revision TKA and bilateral simultaneous TKA patients were excluded. All patients received a standardized multimodal analgesic technique. Surgeries were preferentially performed under spinal anesthesia;

Results

Data from 89 primary unilateral TKA patients were collected and analyzed. Demographic data are displayed in Table 1. There were 37 (41.6%) males in the cohort. The average age was 69.5 years with an average body mass index of 28.4 kg/m². Average length of stay for this unilateral TKA cohort was 1.45 days with 9.0% of patients going home the same day as the procedure. Of the cohort, 21.35% of patients had no listed co-morbidities.

Post-operative results are listed in Table 2. The average visual

Discussion

The opioid epidemic is a national crisis and arthroplasty surgeons have an opportunity to reduce excess narcotics by adjusting prescribing habits. Efforts have been made across all disciplines for enhanced recovery and opioid-reduced or opioid-free anesthesia with multimodal analgesia [13,16,22].

Based on this prospective cohort, a majority of primary unilateral TKA patients are able to be off narcotics after 2-3 weeks, at an average of 16.8 days post-op. Even though 74.2% of patients no longer

Conclusions and Implications of the Study

Although it is difficult to predict specific narcotic requirements for each individual patient, many are able to wean off quickly as 52.8% of patients are off narcotics after 2 weeks, and 74.2% off by 3 weeks post-op. A change in practice to adjust prescribing patterns (average 105.1 pills prescribed) to match patient narcotic usage (52.0 pills taken) could reduce the excess narcotic pills following TKA (average excess 53.1 pills per patient). Pre-operative management of expectations to promote

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Cited by (7)

Opioid Consumption After Discharge From Total Knee and Hip Arthroplasty: A Systematic Review and Meta-Analysis
2024, Journal of Arthroplasty
Pain is challenging after recovery from total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures, and patients often receive prescription opioids. However, opioid consumption by patients remains unclear, and unused opioids may lead to risks including misuse and diversion. The objective of this systematic review and meta-analysis was to compare prescription size versus patient-reported consumption of opioids after discharge following TKA and THA.
PubMed and Embase were systematically searched for publications published between 2015 and 2022 on patient-reported consumption of opioids after TKA and THA. The primary outcome was opioid use in oxycodone 5-mg equivalents. Team members independently reviewed studies for screening, inclusion, data extraction, and risk of bias.
Among the 17 included studies (15 TKA and 11 THA), discharge opioid prescribing exceeded consumption for both TKA (88.4 versus 65.0 pills at 6 weeks) and THA (64.0 versus 29.8 pills at 12 weeks). For both TKA and THA, the range of opioids prescribed varied significantly, by 1.6-fold for TKA and 2.8-fold for THA. Most studies reported pain outcomes (89%) and the use of nonopioid medications (72%). Of the 4 studies offering prescribing recommendations, the amounts ranged from 50 to 104 pills for TKA and 30 to 45 pills for THA.
Opioid prescribing exceeds the amount consumed following TKA and THA. These findings serve as a call to action to tailor prescribing guidelines to how much patients actually consume while emphasizing the use of nonopioid medications to better optimize recovery from surgery.
Reduced Narcotic Utilization in Total Joint Arthroplasty Patients in an Urban Tertiary Care Center
2022, Arthroplasty Today
Citation Excerpt :
Runner et al. found that the average prescribed morphine milligram equivalent (MME) after THA was 452.1 while only 133.8 was taken [25]. The group also looked at opioid prescriptions after TKAs and found the average prescription was for 866.6 MME while 428.2 MME was taken [26]. In both instances, on average, over 50 unneeded opioid pills were prescribed on discharge.
Opioid use after total joint arthroplasty must be balanced against the risks of opioid dependence and diversion. This study sought to define the baseline patient characteristics and discharge opioid use after the initiation of a preoperative and postoperative institutional opioid prescription protocol in a population with a high prevalence of opioid dependence and substance use.
Data on 1004 patients undergoing total joint arthroplasties from July 1, 2017, to June 30, 2019, were retrospectively reviewed. Demographics were collected, and data were grouped into high- and low-discharge opioid groups based on 1 standard deviation above or below the mean. Patient characteristics of the high and low groups were compared using one-way analysis of variance and Pearson chi-square test.
The prevalence of preoperative opioid dependence was 21.8%. The mean discharge opioid prescription was 264 morphine milligram equivalents (MMEs). The cutoffs of high- and low-use groups were above 424 MMEs and below 104.5 MMEs. The high-discharge opioid group was more likely to be male, younger, to have a history of preoperative opioid use, to undergo general anesthesia, and to be uninsured. The lower-discharge opioid group was more likely to be older, female, to have Medicare, and to stay approximately 1 day longer in the hospital. Body mass index, intraoperative opioid requirement, American Society of Anesthesiologists Classification score, race, total knee vs total hip arthroplasty, or surgical approach for total hip arthroplasty did not affect discharge opioid prescriptions.
Reduction of opioid prescriptions at discharge in total joint arthroplasty patients may be possible with the use of preoperative and postoperative protocols, optimizing patient risk factors for opioid use and utilizing a patient-specific opioid taper regimen.
Topical Cannabidiol (CBD) After Total Knee Arthroplasty Does Not Decrease Pain or Opioid Use: A Prospective Randomized Double-Blinded Placebo-Controlled Trial
2022, Journal of Arthroplasty
Multimodal analgesia has become the standard of care for pain management following total knee arthroplasty (TKA). Cannabidiol (CBD) is increasingly utilized in the postoperative period. The purpose of this study was to analyze the analgesic benefits of topical CBD following primary TKA.
In this randomized double-blinded placebo-controlled trial, 80 patients undergoing primary unilateral TKA applied topical CBD (CBD; n = 19), essential oil (EO; n = 21), CBD and essential oil (CBD + EO; n = 21), or placebo (PLA; n = 19) thrice daily around the knee for two weeks postoperatively. This supplemented a standardized multimodal analgesic protocol. Outcomes included visual analog scale (VAS) pain and numeric rating scale (NRS) sleep scores (collected on postoperative day [POD] 0, 1, 2, 7, 14, 42), and cumulative postoperative opioid use (42 days).
Demographic characteristics were similar among the four cohorts. Preoperative VAS and NRS scores were similar among groups. The CBD cohort had a higher mean VAS pain score on POD 2 compared to the EO cohort (CBD: 69.9 ± 19.3 versus. EO: 51.0 ± 18.2; P = .013). No statistically significant differences existed for VAS scores at other times, and no statistically significant differences were observed for postoperative NRS sleep scores or postoperative opioid use at any time point.
Utilization of topical CBD in supplement to multimodal analgesia did not reduce pain or opioid consumption, or improve sleep scores following TKA. These results suggest that the local effects of topical CBD are not beneficial for providing additional pain relief after TKA.
A modern multimodal pain protocol eliminates the need for opioids for most patients following total knee arthroplasty: results from a retrospective comparative cohort study
2023, Journal of Experimental Orthopaedics
Only 1% of Total Knee Arthroplasty Clinical Trials Report Patient Opioid Use Before or After Surgery: A Systematic Review
2023, Clinical Journal of Pain
The duration of postoperative analgesic use after total knee arthroplasty and nomogram for predicting prolonged analgesic use
2022, Frontiers in Surgery

View all citing articles on Scopus

: Source of funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

: Investigation was performed at the Hoag Orthopedic Institute, Irvine, CA

: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2020.01.078.

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Primary KneeOpioid Use After Discharge Following Primary Unilateral Total Knee Arthroplasty: How Much Are We Over-Prescribing?

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusions and Implications of the Study

Prev Med

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Am Coll Surg

Knee

J Arthroplasty

Orthop Clin North Am

J Pediatr Surg

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

Primary Knee
Opioid Use After Discharge Following Primary Unilateral Total Knee Arthroplasty: How Much Are We Over-Prescribing?