Monday, June 13, 2016

Which patients continue to use narcotics after joint replacement?

Trends and predictors of opioid use after total knee and total hip arthroplasty.

These authors asked 574 patients to complete validated, self-report measures of pain, functioning, and mood before and longitudinally for 6 months after total knee (TKA) and total hip (THA) arthroplasty.

Only 8.2% of TKS and 4.3% of THA patients not taking narcotics immediately prior to surgery (opioid-naive) were still using opioids at 6 months. 

In comparison, 53.3% of TKA and 34.7% of THA patients who reported opioid use the day of surgery continued to use opioids at 6 months. 

Patients taking >60 mg oral morphine equivalents preoperatively had an 80% likelihood of persistent use postoperatively. Below is a conversion chart for the different narcotics from this source.

Day of surgery predictors for 6-month opioid use by opioid-naive patients included greater overall body pain (P = 0.002), greater affected joint pain (knee/hip) (P = 0.034), and greater catastrophizing (P = 0.010). 

For both opioid-naive and opioid users on the day of surgery, decreases in overall body pain from baseline to 6 months were associated with decreased odds of being on opioids at 6 months (adjusted odds ratio; however, change in affected joint pain (knee/hip) was not predictive of opioid use.

Among patients who were opioid naive the day of surgery, opioid use at 3 months was associated with a 56 (TKA) and 12 (THA) times greater risk of persistent opioids use at 6 months. These data support developing better monitoring of opioid use before 3 months to consider points of possible intervention.
The authors concluded that many patients taking opioids before surgery continue to use opioids after arthroplasty and some opioid-naive patients remained on opioids; however, persistent opioid use was not associated with change in joint pain.

They hypothesize that the reasons patients continue to use opioids may be due to (1) pain in other areas, (2) self-medicating for affective distress, and (3) therapeutic opioid dependence.

Comment: Management if narcotic medication after joint replacement can be one of the most difficult aspects of the post-athroplasty period, often challenging the harmony of the surgeon-patient relationship. It is helpful to counsel patients using narcotics before surgery that their recovery may be complicated as a result - special arrangements for postoperative pain management should be in place before surgery. Patients still using narcotics at 3 months have a greatly increased likelihood of using them at 6 months.

And then there is this from the CDC (link).

Seth Leopold, editor of CORR, offers this comment "Why not work with these patients in advance of elective surgery to help wean them off these drugs? It is nearly always possible, particularly if one helps patients who need it get help for depression, which often overlaps. But it takes effort and patience, and one cannot be in too much of a hurry to operate. It's worth the wait!"

Point well taken!