Aims. The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. Postal surveys were sent to 1,001 patients on the waiting list for THA or TKA in a single Northern Ireland NHS Trust, which consisted of the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee Scores. Electronic records determined prescriptions since addition to the waiting list and out-of-hour GP and emergency department attendances. Deprivation quintiles were determined by the Northern Ireland Multiple Deprivation Measure 2017 using postcodes of home addresses. Results. Overall, 707 postal surveys were returned, of which 277 (39.2%) reported negative “worse than death” EQ-5D scores and 219 (21.9%) reported the consumption of strong opioids. Those from the least deprived quintile 5 had a significantly better EQ-5D index (median 0.223 (interquartile range (IQR) -0.080 to 0.503) compared to those in the most deprived quintiles 1 (median 0.049 (IQR -0.199 to 0.242), p = 0.004), 2 (median 0.076 (IQR -0.160 to 0.277; p = 0.010), and 3 (median 0.076 (IQR-0.153 to 0.301; p = 0.010). Opioid use was significantly greater in the most deprived quintile 1 compared to all other quintiles (45/146 (30.8%) vs 174/809 (21.5%); odds ratio 1.74 (95% confidence interval 1.18 to 2.57; p = 0.005). Conclusion. More deprived patients have worse health-related quality of life and greater opioid use while waiting for THA and TKA than more affluent patients. For patients awaiting surgery, more information and alternative treatment options should be available. Cite this article: Bone Jt Open 2024;5(5):444–451

Proponents of the direct anterior approach (DAA) for hip arthroplasty (THA) claim lower postoperative pain compared to the posterolateral approach (PA); however, whether that theoretical advantage results in lower opioid consumption is unclear. We sought to investigate the relationship between the DAA and PA on total 90-day predicted opioid consumption in a large cohort. Retrospective analysis identified 2,304 DAA and 6,288 PA primary THAs in patients >18 years old from February 2019 to April 2022. Ninety-day postoperative total morphine milligram equivalent (MME); in-hospital administration, discharge prescriptions, and refills within 90 days were compared between DAA and PA cohorts. Nearest-neighbor matching was performed controlling for age, sex, BMI, ASA, and periarticular injection to evaluate opioid consumption patterns for DAA and PA. Quantile regression was employed to predict the median (50th percentile) MME prescribed by surgical approach. After matching, DAA and PA demonstrated similar median total 90-day prescribed MME (p = 0.008). After adjusting for patient and surgical factors, quantile regression predicted a similar median total 90-day prescribed MME for DAA and PA (243.5 versus 242.7; p = 0.78). While approach did not demonstrate a significant relationship for predicted 90-day MME, other factors including age, sex, BMI, length of stay, peripheral anesthesia, periarticular injection, and white or Caucasian race demonstrated a significant relationship with predicted 90-day MME (p <0.0001). While we identified several risk factors for increased in-hospital and 90-day post-operative opioid consumption, a comparison between DAA and PA did not demonstrate significantly different opioid prescribing patterns

Introduction. Due to the opioid epidemic, our service developed a cultural change highlighted by decreasing discharge opioids after lower extremity arthroplasty. However, concern of potentially increasing refill requests exists. As such, the goal of this study was to analyze whether decreased discharge opioids led to increased postoperative opioid refills. Methods. We retrospectively reviewed 19,428 patients undergoing a primary hip or knee arthroplasty at a single institution from 2016–2019. Patients that underwent secondary procedures within that timeframe were excluded. Two-thousand two-hundred and forty-one patients (12%) were on narcotics preoperatively or had chronic pain syndrome. Two reductions in routine discharge narcotics were performed over this timeframe. First, 8,898 patients routinely received 750 morphine milligram equivalents (MMEs). After the first reduction, 4,842 patients routinely received 520 MMEs. After a second reduction, 5,688 patients routinely received 320 MMEs. We analyzed refill rates, refill MMEs, and whether discharge MMEs were associated with refill MMEs in a multivariate model. Results. Opioid refill rates were 28%, 32%, and 33% in each timeframe (p=0.001). Significantly fewer patients received narcotic refills after 6 weeks in the 320 MME group (8%) compared to the 750 MME group (6%, p=0.02). Total refill MMEs reduced significantly from a mean of 282 in the first to 227 in the last timeframe (p<0.001). After controlling for age, sex, BMI, history of anxiety/depression, and procedure type, opioid discharge of <400 MMEs was not a risk factor for increased refill MMEs in opioid-naïve patients (p=0.23). Conclusion. While decrease in MMEs prescribed at discharge after arthroplasty led to a slight increase in the number of opioid refills (5%), there was a reduction in total refill MMEs. Furthermore, less patients received refills beyond 6 weeks postoperatively. This institutional cultural change led to a reduction in opioid prescriptions after primary arthroplasty equivalent to 500,000 oxycodone 5 mg tablets

Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids. EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies. Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively. Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients

Aims. The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture. Methods. A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support. Results. A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001). Conclusion. This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health. Cite this article: Bone Jt Open 2021;2(2):119–124

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

Excessive postoperative opioid prescribing is a significant contributor to the opioid crisis. Prescribing in orthopaedic surgery is often further complicated by high use of opioid-based preoperative analgesia. ‘Opioid PrEscRiptions and usage After Surgery’ (OPERAS) is an international multicentre prospective student- and trainee-led collaborative study which aims to quantify the amount of opioids prescribed at discharge after common orthopaedic surgeries against what is consumed by patients at 7-days, and assess the impact of opioids on patient-reported outcomes. Data is being collected over 6 14-day periods on consecutive adult patients undergoing shoulder arthroplasty, rotator cuff repair, shoulder labral repair, anterior cruciate ligament repair, hip arthroplasty, and knee arthroplasty, with follow-up via telephone call at 7-days after discharge. The primary outcome is the proportion of oral morphine equivalents (OME) of prescribed opioids versus consumed opioids at 7-days post-discharge. This ongoing study is actively recruiting in over 20 countries. Globally, 65 centres are collecting orthopaedic, including 10 New Zealand centres and 17 Australian centres. To date, 284 orthopaedic patients have been prospectively enrolled with complete data (mean age 59.6 ± 16.7 years; 51.6% female). Overall, 77% and 89% of patients were prescribed opioids on discharge in New Zealand and Australia respectively. On average, 60% of prescribed opioids were consumed at 7-days post-discharge globally (150 OME (75-500) vs. 90 OME (15-200); p<0.01). In New Zealand and Australia, 42.1% (285 OME (150-584) vs. 120 OME (6-210); p<0.01) and 63.3% (150 OME (86-503) vs. 95 OME (28-221); p<0.01) of prescribed opioids were consumed at 7-days, respectively. OPERAS will provide the first high-quality global data on opioid prescription and consumption patterns with patient perspectives. These data can inform prescribing practice and inform guidelines. The growing interest in New Zealand and Australia in student- and trainee-led orthopaedic collaborative research, as evidenced by this study should be actively encouraged and fostered

There have been no studies assessing the acceptability of opioid tapering in the pre-arthroplasty setting. This qualitative study aimed to (1) explore barriers and facilitators to opioid tapering amongst patients with chronic non-cancer pain (CNCP), and (2) explore the similarities and differences in acceptability of opioid tapering between pre-arthroplasty patients and those participating in a biopsychosocial pain management program. From January 2021, adult participants diagnosed with CNCP and taking opioids daily (any dose at time of screening for a period of 3 months) were recruited from either Fairfield Orthopaedic Hip and Knee Service (FOHKS) or Liverpool Hospital Pain Clinic (LHPC). Semi-structured interviews underwent thematic analysis using the framework method. 17 participants were recruited (FOHKS, n=9, mean age 67, female 77%, LHPC, n=8, mean age 54, female 63%). Both groups had participants who; (i) were reluctant to use opioid medications and used them out of “necessity”, (ii) were reluctant to taper due to concerns of worsening pain, quality of life, (iii) believed opioids were “toxins” causing bodily harm. Some FOHKS participants believed tapering should be a post-operative focus, whilst others believed tapering opioids pre-operatively will assist in post-op pain management. Few LHPC participants felt dependent/addicted to opioids, thus driving their intention to taper opioids. The belief of tapering opioids causing worse pain was based on either previous experiences or concerns alone. Some FOHKS participants were more inclined to taper opioids if they were educated on the chronic and peri-operative risks associated with using opioids at time of arthroplasty. Opioid users recognise the harms associated with chronic opioid use and believe they are used out of desperation for adequate analgesia, function, and quality of life. Tapering opioids in the pre-arthroplasty context may need coupling with patient education highlighting the importance of opioid tapering pre-operatively

Excessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid related events, chronic opioid use, and increase the availability of opioids for unlawful diversion. Thus, decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications such as readmissions, emergency department (ED) visits or worsened patient reported outcomes (PROs). The purpose of this quality improvement study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. Methods: Data originated from a statewide arthroplasty database (MARCQI). The database collects over 96% of all TJA performed in the state of Michigan, USA. Data was prospectively abstracted and included OMEs prescribed at discharge, readmissions, ED visits within 30 days and PROs. Data was collected one year before and after the creation of an opioid prescribing protocol that had decreased prescriptions by approximately 50% in opioid naive and tolerant patients. Trends were monitored using Shewhart control charts. 84,998 TJA over two-years were included. All groups showed a reduction in opioids prescribed. Importantly, no increased complications occurred concomitant to this reduction. No increases in ED visits or readmissions, and no decreases in KOOSJR/HOOSJR/PROMIS10 scores were noted in any of the groups. Using large data sets and registries can drive performance and improve quality. The MARCQI Postoperative opioid prescription recommendations and performance measures decreased total oral morphine equivalents prescribed over a large and diverse population by approximately 50% without decreasing PROs or increasing ED visits or hospital readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without an increase in complications across a large population

Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis

In the Unites States, approximately 24% of people undergoing primary total knee or total hip arthroplasty (TKA, THA) are chronic opioid users pre-operatively. Few studies have examined the incidence of opioid use prior to TKA/THA and whether it predicts outcomes post-surgery in the Australian context. The aim was to determine: (i) the proportion of TKA and THA patients who use opioids regularly (daily) pre-surgery; (ii) if opioid use pre-surgery predicts (a) complication and readmission rates to 6-months post-surgery, (b) patient-reported outcomes to 6-months post-surgery. A retrospective cohort study was undertaken utilising linked individual patient-level data from two independent databases comprising approximately 3500 people. Patients had surgery between January 2013 and June 2018, inclusive at Fairfield and Bowral Hospitals. Following data linkage, analysis was completed on 1185 study participants (64% female, 69% TKA, mean age 67 (9.9)). 30% were using regular opioids pre-operatively. Unadjusted analyses resulted in the following rates in those who . were. vs . were not. using opioids pre-operatively (respectively); acute adverse events (39.1% vs 38.6%), acute significant adverse events (5.3% vs 5.7%), late adverse events: (6.9% vs 6.6%), total significant adverse events: (12.5% vs 12.4%), discharge to inpatient rehab (86.4% vs 88.6%), length of hospital stay (5.9 (3.0) vs 5.6 (3.0) days), 6-month post-op Oxford Score (38.8 (8.9) vs 39.5 (7.9)), 6 months post-op EQ-VAS (71.7 (20.2) vs 76.7 (18.2), p<0.001), success post-op described as “much better” (80.2% vs 81.3%). Adjusted regression analyses controlling for multiple co-variates indicated no significant association between pre-op opioid use and adverse events/patient-reported outcomes. Pre-operative opioid use was high amongst this Australian arthroplasty cohort and was not associated with increased risk of adverse events post-operatively. Further research is needed in assessing the relationship between the amount of pre-op opioid use and the risk of post-operative adverse events

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

Introduction. Deaths due to overdose involving opioids have nearly quadrupled in USA in the last 20 years. Several published studies have shown that preoperative opioid use independently predicts perioperative complications in total joint arthroplasty. Our objectives were to (1) assess preoperative opioid consumption in patients undergoing total hip arthroplasty (THA) and (2) to determine how preoperative opioid use affects patient oriented outcomes (POO's) and hip scores before and after THA. Methods. 54 primary THA by a single surgeon were reviewed. A new patient questionnaire was administered to document preoperative opioid consumption (type, dosage and length of use); preoperatively and postoperatively POO's measurements [visual analog scale (VAS), QWB-7, SF-36, and WOMAC] and hip scores were recorded. Patients were stratified into two groups: (1) Opioid Users and (2) Non-Opioid Users. Oral morphine equivalents (OME) were calculated for opioid using patients using standard methodology. Results. 22.2% of the patients were using opioids prior to THA. Among these, 16.6% had tried more than 1 drug. Dosage was self-reported in 33.3% and length of usage only in 8.3%. Mean OME was 13.3mg (range: 6mg–32mg) among users. After adjusting for covariates (gender), opioid users reported worse significant outcomes before surgery for the SF-36 general health (69 vs 80.7; p=0.02), SF-36 role emotional (75.7 vs 99.1; p=0.002), and SF-36 mental health (64 vs 79.7; p=0.005). After surgery even though significant improvements were seen in both groups, opioid users reported significantly worse WOMAC pain scores (1.4 vs 0.3; p=0.03) than non-opioid users. Conclusions. Almost a quarter of the patients in our community undergoing THA, use opioid medications prior to surgery. Opioid users came to surgery with more pain and less function and had worse outcomes. Documentation on the use of opioids in self-administered questionnaire was poor at best. Quantification of OME may help the surgeons with a cutoff point for referral to detoxification before surgery. A significant effort needs to be made in order to measure and manage opioids prior to THA

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed. Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday. Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor

The United States is in the midst of an opioid epidemic, with the World Health Organization reporting that American's consume 99% of the world's supply of hydrocodone and 83% of the world's oxycodone. Additionally, pre-operative opioid use has been associated with worse clinical outcomes and higher rates of complications following TKA. This is especially important in the TKA population given that approximately 15% of patients are either dissatisfied or very dissatisfied at least one year after their TKA procedure. Given the concerning rise is opioid use the American Academy of Orthopaedic Surgeons (AAOS) has recently released an information statement with practice recommendations for combating this excessive and inappropriate opiate use. However, little is known regarding peri-operative opioid use for TKA patients. Therefore, the purpose of this study was to: 1) identify rates of opioid use prior to primary TKA, 2) evaluate post-operative trends in opioid use throughout the year following TKA and 3) identify risk factors for prolonged opioid use following TKA. Overall, 31% of TKA patients are prescribed opioids within 3-months prior to TKA; this percentage has increased over 9% during the years included in this study. Pre-operative opioid use was most predictive of increased refills of opioids following TKA, however, other intrinsic patient characteristics were also predictive of prolonged opioid use. These characteristics remained predictive after controlling for opioid user status. The increasing rates of opioid prescribing prior to TKA are concerning, especially given literature concluding opioids have minimal effect on pain or function in patients with osteoarthritis and pre-operative opioid use is associated with poor outcomes and more complications following TKA. This data provides an important baseline for opioid use trends following TKA that can be used for future comparison and identifies risk factors for prolonged use that will be helpful to prescribers as the AAOS works to decreased opioid use, misuse and abuse within the United States. Our data on THA and unicompartmental arthroplasty is similar with an increase in pre-THA use of 9% with 38% receiving narcotics within 3 months of surgery and continued use in opioid users (9 times non-opioid users at 12 months)

Introduction. The prescription of opioids has increased in the last two decades. Recently, several states have developed online Prescription Drug Monitoring Programs aimed at preventing overprescribing of controlled substances. Unicompartmental knee arthroplasty (UKA) has been shown to provide improved early functional outcomes, faster recovery, and less postoperative morbidity and pain than total knee arthroplasty (TKA). The aim of this study is to evaluate differences in opioid prescription requirements between patients undergoing TKA and UKA. Methods. We retrospectively reviewed consecutive series of primary TKA from January 2017 to July 2017 and primary UKA from January 2016 to July 2017 using standardized perioperative pain protocols. All patients that underwent any other procedure 6 months prior to and after index surgery were excluded, resulting in 740 TKA and 241 UKA. Demographic and comorbidity information was collected for all patients. Opioid prescriptions, morphine milligram equivalents (MME), sedatives, benzodiazepines, and stimulants were collected from State Controlled Substance Monitoring website 6 months prior and after index procedures. Univariate and multivariate analysis were performed for patients that had a second prescription and continued use (defined as more than 6 months postoperatively). Results. Patients undergoing UKA had a second opioid prescription filled 50.2% of the time compared to 60.5% for TKA (p=0.006). In addition, continued opioid use after 6 months was 8.3% in UKAs compared to 11.8% in TKAs (p=0.149). When controlling for potential confounders, patients undergoing UKA were less likely to require a second prescription than TKA patients (adjusted odds ratio: 0.603 (95% Confidence Interval (CI): 0.425–0.855). In addition, continued use of opioids after 6 months was also reduced compared to patients undergoing TKA (adjusted OR: 0.51, 95% CI: 0.27–0.97) in the multivariate analysis. Other independent predictors of continued opioid use include obesity (OR 1.79, 95% CI 1.07–3.00) and preoperative opioid use (OR 1.66 per script, 95% CI: 1.49–1.86). Our models for second script and continued use reported AUC scores of 0.65 and 0.85, respectively. Conclusion. Patients with UKA are less likely to require a second opioid prescription and have continued opioid use even when controlling for a variety of potential confounders. Given the reduced opioid requirements associated with UKA, this study supports that orthopaedic surgeons should adjust their prescription patterns and educate patients regarding expected analgesic needs. Due to the retrospective nature of this study we were unable to precisely quantify the amount of opioids consumed in these patient groups. An ongoing prospective study will more accurately determine the duration and quantity of opioid use after UKA compared to TKA

Background. Postoperative recovery after routine total hip arthroplasty (THA) can lead to the development of prolonged opioid use but there are few tools for predicting this adverse outcome. The purpose of this study was to develop machine learning algorithms for preoperative prediction of prolonged post-operative opioid use after THA. Methods. A retrospective review of electronic health records was conducted at two academic medical centers and three community hospitals to identify adult patients who underwent THA for osteoarthritis between January 1. st. , 2000 and August 1. st. , 2018. Prolonged postoperative opioid prescriptions were defined as continuous opioid prescriptions after surgery to at least 90 days after surgery. Five machine learning algorithms were developed to predict this outcome and were assessed by discrimination, calibration, and decision curve analysis. Results. Overall, 5507 patients underwent THA, of which 345 (6.3%) had prolonged postoperative opioid prescriptions. The factors determined for prediction of prolonged postoperative opioid prescriptions were: age, duration of pre-operative opioid exposure, preoperative hemoglobin, and certain preoperative medications (anti-depressants, benzodiazepines, non-steroidal anti-inflammatory drugs, and beta-2-agonists). The elastic-net penalized logistic regression model achieved the best performance across discrimination (c-statistic = 0.77), calibration, and decision curve analysis. This model was incorporated into a digital application able to provide both predictions and explanations; available here: . https://sorg-apps.shinyapps.io/thaopioid/. Conclusion. If externally validated in independent populations, the algorithms developed in this study could improve preoperative screening and support for THA patients at high-risk for prolonged postoperative opioid use. Early identification and intervention in high-risk cases may mitigate the long-term adverse consequence of opioid dependence. For any tables or figures, please contact the authors directly

The United States is in the midst of an opioid epidemic, with the World Health Organization reporting that American's consume 99% of the world's supply of hydrocodone and 83% of the world's oxycodone. Additionally, pre-operative opioid use has been associated with worse clinical outcomes and higher rates of complications following total knee arthroplasty (TKA). This is especially important in the TKA population given that approximately 15% of patients are either dissatisfied or very dissatisfied at least one year after their TKA procedure. Given the concerning rise in opioid use the American Academy of Orthopaedic Surgeons (AAOS) has recently released an information statement with practice recommendations for combating this excessive and inappropriate opiate use. However, little is known regarding peri-operative opioid use for TKA patients. Therefore, the purpose of this study was to: 1) identify rates of opioid use prior to primary TKA, 2) evaluate post-operative trends in opioid use throughout the year following TKA and 3) identify risk factors for prolonged opioid use following TKA. Overall, 31% of TKA patients are prescribed opioids within 3-months prior to TKA; this percentage has increased over 9% during the years included in this study. Pre-operative opioid use was most predictive of increased refills of opioids following TKA, however, other intrinsic patient characteristics were also predictive of prolonged opioid use. These characteristics remained predictive after controlling for opioid user status. The increasing rates of opioid prescribing prior to TKA are concerning, especially given literature concluding opioids have minimal effect on pain or function in patients with osteoarthritis and pre-operative opioid use is associated with poor outcomes and more complications following TKA. This data provides an important baseline for opioid use trends following TKA that can be used for future comparison and identifies risk factors for prolonged use that will be helpful to prescribers as the AAOS works to decreased opioid use, misuse and abuse within the United States

Introduction. Despite evidence-based recommendations opioids and benzodiazepines are commonly prescribed to treat osteoarthritis. This study aims to quantify the prevalence of opioid and benzodiazepine prescriptions given for the primary diagnosis of osteoarthritis across a large healthcare system. Additionally, we aim to characterize risk factors for drug misuse, abuse, and diversion. Methods. We conducted a descriptive analysis of adult patient encounters with a primary diagnosis of osteoarthritis during a one-year time period from Jan –Dec 2016 at a large, healthcare system. Demographic data, prescription data, patient-specific prescription drug use risk criteria were collected. Descriptive analysis was conducted to characterize the population of arthritis patients who received prescription opioids. The rate of controlled substance prescribing was calculated for the population as a whole and among subgroups (age, facility type, and patient risk profile). Results. During the one-year time frame, our system had 45,341 outpatient encounters with a primary diagnosis of osteoarthritis. Almost a third of these encounters resulted in a prescription for an opioid or benzodiazepine (n = 7,375; 31.9%). The majority of patients were between ages 18 and 64 (57.1%), with 42.9% patients >65. While 38.8% were prescribed in an acute care setting (ED or Urgent Care), the majority were in outpatient clinics (58.8%) with 36.2 % of outpatient encounters originating from orthopaedic clinics. 14.3% of those who received a prescription had a risk factor for prescription misuse, the most prevalent being “early refill” (7.0%). Conclusion. Opioids remain a prevalent treatment for osteoarthritis, given in over a third of encounters. These prescriptions pose a risk for adverse outcomes, since over a third of patients had a risk factor for misuse. Continued efforts to improve compliance with evidence-based guidelines as well as alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis

Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis