CHRONIC PAIN

Incidence of Preop Opioids.

Treatment of refractory pain is the primary reason for TJA.  Thus many patients are taking preoperative pain medication, with up to 30-40% using narcotic analgesia for osteoarthritis [1] [2]. 

One of the major problems is that medical organizations are advocating for the long-term use of opioids for osteoarthritis management due to association between NSAIDs and gastric ulcers.  In 2009, the American Geriatric Society, the American Pain Society, and National Institute for Health and Care Excellence (UK) offered similar recommendations for a trial of opioid therapy in older patients with osteoarthritis causing moderate to severe persistent pain refractory to NSAIDS and Tylenol [3]. The AAOS does not offer a recommendation for or against.

The CDC offers guidelines for opioid use in chronic pain.  Recommendations include establishing treatment goals, setting realistic expectations for pain and function, explaining that opioid therapy should only be continued with meaningful improvements, discuss risk of addiction and increased risk of overdose with a dosage > 50 morphine milligram equivalents (MME) per day (~ 33 mg oxycodone or 50 mg of hydrocodone). Physicians should avoid extended-release medications, prescribe the lowest effective dose, and obtain urine drug testing before starting long-term opioid therapy.  Patients should be re-evaluated within 2-4 weeks initially and then every 12 weeks to ensure benefits greater than risks. 

Effect on TJA Outcome.

- Lower patient reported outcomes in THA and TKA associated with chronic opioid use [4] [5].

- Increased risk for complications and increased risk revision surgery in TKA [5] [6]. Revisions particularly associated with postop stiffness secondary to pain.

- Greater postoperative pain [1]. 

- Greater postoperative opioid use. Pevic et al found that opioid group compared to opioid-naïve group required significant higher dosages of opioids during postop hospitalization, higher risk of continued opioid use after 6 weeks, and worse Harris Hip Score at final follow up [7].  More encouraging however, was the finding that over 50% of patients taking preop opioids were completely off by 6 weeks, and 80% were weaned off by final follow up (average 54 months).

-Prolonged Opioid Use in THA and TKA. Preoperative opioid use is a significant risk factor for prolonged postoperative (> 6 months) opioid use.  In patients not taking narcotics preoperatively, about 8% of TKA and 4% of THA patients required opioids > 6 months after surgery.  In contrast, patients using opioids preoperatively had a 53% and 35% risk of continuing opioids at 6 months, in TKA and THA respectively.  Patients on higher doses of opioids preop had 80% risk of continuing opioids at 6 months.  [8]

- Opioids are correlated with an increased risk of falls in the elderly, increasing the risk for periprosthetic fractures[9].

REFERENCE

1.         Aasvang, E.K., et al., Chronic pre-operative opioid use and acute pain after fast-track total knee arthroplasty. Acta Anaesthesiol Scand, 2016. 60(4): p. 529-36.

2.         Menendez, M.E., D. Ring, and B.T. Bateman, Preoperative Opioid Misuse is Associated With Increased Morbidity and Mortality After Elective Orthopaedic Surgery. Clin Orthop Relat Res, 2015. 473(7): p. 2402-12.

3.         Chou, R., et al., Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain, 2009. 10(2): p. 113-30.

4.         Zywiel, M.G., et al., Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am, 2011. 93(21): p. 1988-93.

5.         Nguyen, L.L., D.C. Sing, and K.J. Bozic, Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty. J Arthroplasty, 2016.

6.         Ben-Ari, A., H. Chansky, and I. Rozet, Preoperative Opioid Use Is Associated with Early Revision After Total Knee Arthroplasty: A Study of Male Patients Treated in the Veterans Affairs System. J Bone Joint Surg Am, 2017. 99(1): p. 1-9.

7.         Pivec, R., et al., Opioid use prior to total hip arthroplasty leads to worse clinical outcomes. Int Orthop, 2014. 38(6): p. 1159-65.

8.         Goesling, J., et al., Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain, 2016. 157(6): p. 1259-65.

9.         Stevens, J.A., et al., The costs of fatal and non-fatal falls among older adults. Inj Prev, 2006. 12(5): p. 290-5.