These authors tested the hypothesis that use of opioids is associated with one year adverse outcomes after total knee arthroplasty(TKA).
The length of time for which an opioid had been prescribed by the VA and the morphine equivalent dose were calculated for each patient. Patients for whom opioids had been prescribed for >3 months in the year prior to the TKA were assigned to the long-term opioid group.
Of 32,636 patients 12,772 (39.1%) were in the long-term opioid group and 734 (2.2%) had a revision within a year after the TKA.
Chronic kidney disease, diabetes, and long-term opioid use were associated with revision within 1 year—with odds ratios (95% confidence intervals [CIs]) of 1.76 (1.37 to 2.22), 1.11 (0.93 to 1.31), and 1.40 (1.19 to 1.64), respectively
The authors concluded that long-term opioid use prior to TKA was associated with an increased risk of knee revision during the first year after TKA among predominantly male patients treated in the VA system.
Comment: This study of a large series of total knee patients is likely to have relevance to all patients having arthroplasty, including those having shoulder joint replacement. It prompts us to consider two questions: (1) what does prescribed narcotic use say about the patient? and (2) what prompts patients to have a revision? The use of narcotics may indicate a low pain tolerance. The indications for revision include continued pain after surgery. It seems likely that the patient with preoperative pain 'requiring' narcotics may be more likely to have persisting pain after surgery and that pain may increase the risk of revision.
While this study compare patients taking and not taking prescribed narcotics, their data show that 'taking narcotics' is not dichotomous, but a wide range of dose, frequency and duration. The chart below shows the number of morphine equivalent doses per month on the horizontal axis and the length of time the narcotics were prescribed on the vertical axis. Patients taking more narcotics also were on narcotics for longer periods of time. It would be of interest to know the relationship of revision rate to the amount of narcotics prescribed. The patients at the lower left of this chart might be expected to be at lower revision risk than those at the upper right.
So how do we use these data in our practice? First, we need to inform patients that preoperative narcotic use is likely to be associated with continued pain after surgery. Second, we need to consider delaying elective surgery on patients with minimal radiographic findings who are taking narcotics. Third, when an arthroplasty fails to provide the desired pain relief, we need to be cautious about offering revision surgery to patients with pain alone (i.e. without obvious mechanical failure or infection). Fourth, the non-operative management of a painful joint should not include the prescription of narcotic medication.
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