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Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study

  • Orthopaedic Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

Optimized health system approaches to improving guideline-congruent care require evaluation of multilevel factors associated with prescribing practices and outcomes after total knee and hip arthroplasty.

Materials and methods

Electronic health data from patients who underwent a total knee or hip arthroplasty between January 2016–January 2020 in the Military Health System Data were retrospectively analyzed. A generalized linear mixed-effects model (GLMM) examined the relationship between fixed covariates, random effects, and the primary outcome (30-day opioid prescription refill).

Results

In the sample (N = 9151, 65% knee, 35% hip), the median discharge morphine equivalent dose was 660 mg [450, 892] and varied across hospitals and several factors (e.g., joint, race and ethnicity, mental and chronic pain conditions, etc.). Probability of an opioid refill was higher in patients who underwent total knee arthroplasty, were white, had a chronic pain or mental health condition, had a lower age, and received a presurgical opioid prescription (all p < 0.01). Sex assigned in the medical record, hospital duration, discharge non-opioid prescription receipt, discharge morphine equivalent dose, and receipt of an opioid-only discharge prescription were not significantly associated with opioid refill.

Conclusion

In the present study, several patient-, care-, and hospital-level factors were associated with an increased probability of an opioid prescription refill within 30 days after arthroplasty. Future work is needed to identify optimal approaches to reduce unwarranted and inequitable healthcare variation within a patient-centered framework.

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Data availability

All data generated or analyzed in this study are not included in this published article. The data is sourced from the US Department of Defense and cannot be made available directly to the public or individual researchers by the authors. Any request for data would need to go through the appropriate procedures (e.g., data sharing agreements) and authorities (Defense Health Agency).

References

  1. Agency for Healthcare Research and Quality (2021) HCUP Fast Stats: 2018 U.S. National Inpatient Stays(ed)^(eds) Healthcare Cost and Utilization Project (HCUP), Rockville, MD.

  2. Amen TB, Varady NH, Rajaee S, Chen AF (2020) Persistent racial disparities in utilization rates and perioperative metrics in total joint arthroplasty in the US: a comprehensive analysis of trends from 2006 to 2015. JBJS 102(9):811–820

    Article  Google Scholar 

  3. Bates D, Mächler M, Bolker B, Walker S (2014) Fitting linear mixed-effects models using lme4. arXiv preprint arXiv:1406.5823. Accessed 22 Apr 2022

  4. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD (2010) Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 468(1):57–63

    Article  PubMed  Google Scholar 

  5. Brichetto G, Monti Bragadin M, Fiorini S et al (2020) The hidden information in patient-reported outcomes and clinician-assessed outcomes: multiple sclerosis as a proof of concept of a machine learning approach. Neurol Sci 41(2):459–462

    Article  PubMed  Google Scholar 

  6. Brummett CM, Waljee JF, Goesling J et al (2017) New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg 152(6):e170504

    Article  PubMed  PubMed Central  Google Scholar 

  7. Buys MJ, Bayless K, Romesser J et al (2020) Opioid use among veterans undergoing major joint surgery managed by a multidisciplinary transitional pain service. Reg Anesth Pain Med 45(11):847–852

    Article  PubMed  PubMed Central  Google Scholar 

  8. Chen EY, Lasky R, Dotterweich WA, Niu R, Tybor DJ, Smith EL (2019) Chronic prescription opioid use before and after total hip and knee arthroplasty in patients younger than 65 years. J Arthroplasty 34(10):2319–2323

    Article  PubMed  Google Scholar 

  9. Chou R, Gordon DB, de Leon-Casasola OA et al (2016) Management of postoperative pain: a clinical practice guideline from the American pain society, the American society of regional anesthesia and pain medicine, and the American society of anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. J Pain 17(2):131–157

    Article  PubMed  Google Scholar 

  10. Chun DS, Leonard AK, Enchill Z, Suleiman LI (2021) Racial disparities in total joint arthroplasty. Curr Rev Musculoskelet Med 14(6):434–440

    Article  PubMed  PubMed Central  Google Scholar 

  11. Dover DC, Belon AP (2019) The health equity measurement framework: a comprehensive model to measure social inequities in health. Int J Equity Health 18(1):36

    Article  PubMed  PubMed Central  Google Scholar 

  12. Dowell D, Haegerich TM, Chou R (2016) CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA 315(15):1624–1645

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Grobaty L, Lajam C, Hutzler L (2020) Impact of value-based reimbursement on health-care disparities for total joint arthroplasty candidates. JBJS Rev 8(11):e2000073

    Article  PubMed  Google Scholar 

  14. Hansen CA, Inacio MCS, Pratt NL, Roughead EE, Graves SE (2017) Chronic use of opioids before and after total knee arthroplasty: a retrospective cohort study. J Arthroplasty 32(3):811-817.e811

    Article  PubMed  Google Scholar 

  15. Hoffman KM, Trawalter S, Axt JR, Oliver MN (2016) Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci USA 113(16):4296–4301

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Kassambara A (2023) ggpubr: ‘ggplot2’ Based Publication Ready Plots. R package version 0.6.0. https://rpkgs.datanovia.com/ggpubr/. Accessed 1 Mar 2023

  17. Kopp SL, Børglum J, Buvanendran A et al (2017) Anesthesia and analgesia practice pathway options for total knee arthroplasty: an evidence-based review by the american and european societies of regional anesthesia and pain medicine. Reg Anesth Pain Med 42(6):683–697

    Article  PubMed  Google Scholar 

  18. Kugelman DN, Mahure SA, Feng JE, Rozell JC, Schwarzkopf R, Long WJ (2021) Total knee arthroplasty is associated with greater immediate post-surgical pain and opioid use than total hip arthroplasty. Arch Orthop Trauma Surg. 142(12):3575–3580

    Article  PubMed  Google Scholar 

  19. Lewis GN, Rice DA, McNair PJ, Kluger M (2015) Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesth. 114(4):551–561

    Article  CAS  PubMed  Google Scholar 

  20. Lindner M, Nosseir O, Keller-Pliessnig A, Teigelack P, Teufel M, Tagay S (2018) Psychosocial predictors for outcome after total joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC Musculoskelet Disord 19(1):159–159

    Article  PubMed  PubMed Central  Google Scholar 

  21. Ludecke D (2018) ggeffects: tidy data frames of marginal effects from regression models. J Open Sourc Soft 3(26):772

    Article  Google Scholar 

  22. Namba RS, Singh A, Paxton EW, Inacio MCS (2018) Patient factors associated with prolonged postoperative opioid use after total knee arthroplasty. J Arthroplasty 33(8):2449–2454

    Article  PubMed  Google Scholar 

  23. Neuprez A, Neuprez AH, Kaux J-F et al (2017) Early clinically relevant improvement in quality of life and clinical outcomes 1 year postsurgery in patients with knee and hip joint arthroplasties. Cartilage 9(2):127–139

    Article  PubMed  PubMed Central  Google Scholar 

  24. Nguyen L-CL, Sing DC, Bozic KJ (2016) Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplasty 31(9):282–287

    Article  PubMed  Google Scholar 

  25. Nouraee CM, McGaver RS, Schaefer JJ et al (2022) Opioid-prescribing practices between total knee and hip arthroplasty in an outpatient versus inpatient setting. J Healthc Qual. 44(2):95–102

    Article  PubMed  Google Scholar 

  26. Novikov D, Cizmic Z, Feng JE, Iorio R, Meftah M (2018) The historical development of value-based care: how we got here. JBJS 100(22):e144

    Article  Google Scholar 

  27. Politzer CS, Kildow BJ, Goltz DE, Green CL, Bolognesi MP, Seyler TM (2018) Trends in opioid utilization before and after total knee arthroplasty. J Arthroplasty. 33(7s):S147-153.e141

    Article  PubMed  Google Scholar 

  28. Pryymachenko Y, Wilson RA, Abbott JH, Dowsey MM, Choong PFM (2020) Risk factors for chronic opioid use following hip and knee arthroplasty: evidence from new Zealand population data. J Arthroplasty 35(11):3099-3107.e3014

    Article  PubMed  Google Scholar 

  29. Ripollés-Melchor J, Abad-Motos A, Díez-Remesal Y et al (2020) association between use of enhanced recovery after surgery protocol and postoperative complications in total hip and knee arthroplasty in the postoperative outcomes within enhanced recovery after surgery protocol in elective total hip and knee arthroplasty study (POWER2). JAMA Surg 155(4):e196024

    Article  PubMed  PubMed Central  Google Scholar 

  30. Roebke AJ, Via GG, Everhart JS et al (2020) Inpatient and outpatient opioid requirements after total joint replacement are strongly influenced by patient and surgical factors. Bone Jt Open 1(7):398–404

    Article  PubMed  PubMed Central  Google Scholar 

  31. Ruddell JH, Reid DBC, Shah KN et al (2021) Larger initial opioid prescriptions following total joint arthroplasty are associated with greater risk of prolonged use. J Bone Joint Surg 103(2):106–114 (American volume)

    Article  PubMed  Google Scholar 

  32. Sabatino MJ, Kunkel ST, Ramkumar DB, Keeney BJ, Jevsevar DS (2018) Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures. J Bone Joint Surg 100(3):180–188 (American volume)

    Article  PubMed  Google Scholar 

  33. Samra R, Hankivsky O (2021) Adopting an intersectionality framework to address power and equity in medicine. The Lancet 397(10277):857–859

    Article  Google Scholar 

  34. Shah A, Hayes CJ, Martin BC (2017) Characteristics of initial prescription episodes and likelihood of long-term opioid use&mdash;United States, 2006&ndash;2015. MMWR Morb Mortal Wkly Rep 66:265–269

    Article  PubMed  PubMed Central  Google Scholar 

  35. Sheth DS, Ho N, Pio JR, Zill P, Tovar S, Namba RS (2020) Prolonged opioid use after primary total knee and total hip arthroplasty: prospective evaluation of risk factors and psychological profile for depression, pain catastrophizing, and aberrant drug-related behavior. J Arthroplasty 35(12):3535–3544

    Article  PubMed  Google Scholar 

  36. Soffin EM, Wilson LA, Liu J, Poeran J, Memtsoudis SG (2021) Association between sex and perioperative opioid prescribing for total joint arthroplasty: a retrospective population-based study. Br J Anaesth 126(6):1217–1225

    Article  CAS  PubMed  Google Scholar 

  37. Sorel J, Veltman E, Honig A, Poolman R (2019) The influence of preoperative psychological distress on pain and function after total knee arthroplasty: a systematic review and meta-analysis. Bone Joint J 101(1):7–14

    Article  PubMed  Google Scholar 

  38. Subirana I, Sanz H, Vila J (2014) Building bivariate tables: the comparegroups package for R. J Stat Softw 1(12):2014

    Google Scholar 

  39. Traven SA, Brinton DL, Woolf SK, Leddy LR, Gottschalk MB, Slone HS (2021) Notable variability in opioid-prescribing practices after common orthopaedic procedures. J Am Acad Orthop Surg. 29(5):219–226

    Article  PubMed  Google Scholar 

  40. Vaz KM, Huang PS, Copp SN (2019) Standardized opioid prescription protocol reduces opioid consumption after total joint arthroplasty. J Am Acad Orthop Surg Glob Res Rev. 3(12):e19.00163

    PubMed  PubMed Central  Google Scholar 

  41. Whale CS, Henningsen JD, Huff S, Schneider AD, Hijji FY, Froehle AW (2020) Effects of the Ohio opioid prescribing guidelines on total joint arthroplasty postsurgical prescribing and refilling behavior of surgeons and patients. J Arthroplasty 35(9):2397–2404

    Article  PubMed  Google Scholar 

  42. Wickham H (2016) ggplot2: elegent graphics for data analysis. Springer-Verlag, New York, New York

    Book  Google Scholar 

  43. Wilson Y, White A, Jefferson A, Danis M (2019) Intersectionality in clinical medicine: the need for a conceptual framework. Am J Bioeth 19(2):8–19

    Article  PubMed  Google Scholar 

  44. Woo A, Lechner B, Fu T et al (2015) Cut points for mild, moderate, and severe pain among cancer and non-cancer patients: a literature review. Ann Palliat Med 4(4):176–183

    PubMed  Google Scholar 

  45. Young JC, Dasgupta N, Chidgey BA, Jonsson Funk M (2021) Postsurgical opioid prescriptions and risk of long-term use: an observational cohort study across the United States. Ann Surg 273(4):743–750

    Article  PubMed  Google Scholar 

  46. Zalon ML (2014) Mild, moderate, and severe pain in patients recovering from major abdominal surgery. Pain Manag nursing 15(2):e1–e12

    Article  Google Scholar 

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Funding

Funding for this project was provided by the Uniformed Services University through Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. under Cooperative Agreement #HU00011920042.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA

    Krista B. Highland, Germaine F. Herrera, Austin G. Bell, Kyle L. Cyr, Alexander G. Velosky & Michael S. Patzkowski

  2. School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA

    Hillary A. Sowa

  3. Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA

    Germaine F. Herrera & Alexander G. Velosky

  4. Department of Anesthesia, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20910, USA

    Austin G. Bell & Kyle L. Cyr

  5. Department of Orthopaedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, TX, 78234-6200, Fort Sam Houston, USA

    Jeanne C. Patzkowski

  6. Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA

    Jeanne C. Patzkowski

  7. Emory University, 201 Dowman Drive, Atlanta, GA, 30322, USA

    Trevor Kanter

  8. Department of Anesthesiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6200, USA

    Michael S. Patzkowski

  9. Department of Anesthesiology, Dwight D. Eisenhower Army Medical Center, 300, E Hospital Rd, Fort Gordon, GA, 30905, USA

    Austin G. Bell

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Contributions

All authors contributed to the present manuscript, to include contributing to the (1) conceptualization, (2) interpretation of analytic results, (3) writing of the first draft, (4) and editing of the first draft. Krista Highland provided supervision; Krista Highland and Alexander Velosky contributed to the methodology and formal analysis and investigation.

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Correspondence to Krista B. Highland.

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Highland, K.B., Sowa, H.A., Herrera, G.F. et al. Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study. Arch Orthop Trauma Surg 143, 5539–5548 (2023). https://doi.org/10.1007/s00402-023-04853-7

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