P-080 - Opioid Consumption Patterns Before and After Elective Joint Replacement Surgery

Abstract Title: Opioid Consumption Patterns Before and After Elective Joint Replacement Surgery

Background: Opioid use is associated with multiple risks including accidental overdose and addiction. Many patients receive their first exposure to opioids following an elective procedure with some transitioning to persistent opioid use.¹ Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are among the most common elective procedures. For patients undergoing these procedures, opioids may be prescribed for pain control pre- and postoperatively. The goal of surgery is to relieve patients of their joint pain and reduce dependence on analgesics, but these procedures can result in persistent opioid use.²

Preoperative opioid use is associated with higher volume of opioid refills, utilization of more potent opioids, and higher daily oral morphine equivalent consumption.³ Risk factors associated with persistent postoperative opioid use include younger age, female sex, depression, and preoperative opioid use.⁴ It is important that healthcare providers understand patient opioid utilization before and after total joint arthroplasty, as strategies to minimize overprescribing and opioid consumption may be identified.

Purpose/Objectives: The purpose of this retrospective study is to describe prescription opioid consumption patterns before and after total hip (THA) or knee arthroplasty (TKA) in preoperative opioid users and nonchronic opioid users at Kaiser Permanente Washington (KPWA).

Methods: Patients were included if they underwent elective THA or TKA surgery between June 2018 and June 2022, were 18 years or older on the day of surgery and had prescription drug coverage for 3 months before and 12 months after surgery. Medical claims were used to identify elective joint surgeries and determine the use of peripheral nerve blocks. Pharmacy claims were used to identify opioid prescribed, dispense date, quantity prescribed, and morphine milligram equivalent (MME). Patients were stratified by THA vs. TKA and nonchronic opioid users vs. preoperative opioid users. A preoperative opioid user was defined as a patient who had filled two or more opioid prescriptions in the 3-month preoperative period. Exclusion criteria included active malignancy, acute trauma, revision surgery, and patients with postoperative complications.

The primary outcome of interest was the proportion of patients taking opioids 10-12 months postoperatively, stratified by preoperative opioid use. Secondary outcomes of interest included the most common opioids filled and the proportion of patients who received peripheral nerve blocks. A Chi-square test was used to evaluate the relationship between preoperative opioid use and continued use of opioids 1-year postoperatively. Statistical significance was set at P< .05.


Results: Of 8,886 patients who underwent a TKA or THA, 24% were considered preoperative opioid users, 3,842 (43%) underwent THA and 5,044 (57%) underwent TKA. The average age was 68 years and 59% of patients were female. Over the study period, the total number of opioid prescriptions filled was 43,326. The total number of prescriptions filled for THA patients was 15,452 (36%) and 27,874 (64%) for TKA patients. The average number of prescriptions filled was 4.0 and 5.5 per THA patient and TKA patient, respectively.

At 10-12 months post-surgery, 39% of preoperative opioid users continued using opioids compared with 9% of nonchronic opioid users who became persistent opioid users (P< .05). Exploratory analysis showed factors associated with higher likelihood of persistent opioid use 10-12 months post-surgery include female sex and undergoing TKA procedure. The most common prescription was for oxycodone (42%) followed by hydrocodone/acetaminophen (24%) and oxycodone/acetaminophen (13%). The use of peripheral nerve blocks was not associated with a lower rate of continued opioid use 10-12 months postoperatively.

Conclusions/Implications for future research and/or clinical care: Persistent use of opioids after surgery is one of the most common surgical complications. Even in patients who were not on opioids before surgery, 9% remained on opioids 1 year after surgery. Our results indicate that preoperative opioid use, female sex, and undergoing a TKA procedure are factors associated with persistent postoperative opioid use. Understanding patient specific factors associated with opioid utilization after total joint arthroplasty is essential to identifying strategies to minimize overprescribing and promote rational opioid use. One way to mitigate the risks associated with postoperative opioid use is the implementation of opioid stewardship programs. Opioid stewardship programs are designed to reduce opioid overuse, misuse, and abuse, ultimately helping prevent addiction while treating pain effectively. Pharmacists at KPWA are well-suited to provide opioid education within the health care system and can empower the care team to work closely with patients to develop a multimodal approach to pain management.


References:

1. Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults [published correction appears in JAMA Surg. 2019 Mar 1;154(3):272]. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504


2. Chen EY, Lasky R, Dotterweich WA, Niu R, Tybor DJ, Smith EL. Chronic Prescription Opioid Use Before and After Total Hip and Knee Arthroplasty in Patients Younger Than 65 Years. J Arthroplasty. 2019;34(10):2319-2323. doi:10.1016/j.arth.2019.05.050


3. Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg. 2017;125(5):1733-1740. doi:10.1213/ANE.0000000000002458


4. Zarling BJ, Yokhana SS, Herzog DT, Markel DC. Preoperative and Postoperative Opiate Use by the Arthroplasty Patient. J Arthroplasty. 2016;31(10):2081-2084. doi:10.1016/j.arth.2016.03.061