Elsevier

The Journal of Arthroplasty

Volume 32, Issue 9, September 2017, Pages 2658-2662
The Journal of Arthroplasty

Health Policy & Economics
Preoperative Opiate Use Independently Predicts Narcotic Consumption and Complications After Total Joint Arthroplasty

https://doi.org/10.1016/j.arth.2017.04.002Get rights and content

Abstract

Background

Multimodal pain protocols have reduced opioid requirements and decreased complications after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, these protocols are not universally effective. The purposes of this study are to determine the risk factors associated with increased opioid requirements and the impact of preoperative narcotic use on the length of stay and inhospital complications after THA or TKA.

Methods

We prospectively evaluated a consecutive series of 802 patients undergoing elective primary THA and TKA over a 9-month period. All patients were managed using a multimodal pain protocol. Data on medical comorbidities and history of preoperative narcotic use were collected and correlated with deviations from the protocol.

Results

Of the 802 patients, 266 (33%) required intravenous narcotic rescue. Patients aged <75 years (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.10-3.12; P = .019) and with preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P < .001) were more likely to require rescue. Multivariate logistic regression analysis demonstrated that preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P < .001) was the largest independent predictor of increased postoperative opioid requirements. These patients developed more inhospital complications (OR, 1.92; 95% CI, 1.34-2.76; P < .001). This was associated with an increased length of stay (OR, 1.59; 95% CI, 1.06-2.37; P = .025) and a 2.5-times risk of requiring oral narcotics at 3 months postoperatively (OR, 2.48; 95% CI, 1.61-3.82; P < .001).

Conclusion

Despite the effectiveness of multimodal postoperative pain protocols, younger patients with preoperative history of narcotic use require additional opioids and are at a higher risk for complications and a greater length of stay.

Section snippets

Patients and Methods

We prospectively evaluated a consecutive series of 802 elective, primary THA (n = 273) and TKA (n = 529) patients at a single institution over a 9-month period. This study was approved and conducted according to the guidelines set by our institutional review board. Patients aged <18 years and those who underwent arthroplasty procedures for fracture or malignancy were excluded from the study. There were 324 men and 478 women with a mean age of 62.3 years (range, 20-92 years). Preoperative

Results

In this consecutive series of unselected patients undergoing primary THA and TKA, 266 patients (33%) required IV narcotic rescue medications. One hundred eighty patients required rescue on day 0, 77 patients on day 1, 7 on day 2, and 2 on day 3 postoperatively. Hydromorphone was the most common rescue narcotic administered. After surgery, 183 TKAs (34.6%) compared with 83 THAs (30.4%) patients required additional opioids (P = .251). The average BMI in patients who required IV narcotic rescue

Discussion

Although advances in pain management have decreased postoperative opioid requirements in patients undergoing THA and TKA [21], [22], [23], utilization in patients undergoing THA or TKA remains high. The American Academy of Orthopaedic Surgeons along with other public health agencies has advocated for a reduction in opioid prescriptions and consumption in the midst of a national opioid epidemic [24]. Furthermore, ORAEs are the leading causes of inhospital complications and delays in hospital

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    Investigation was performed at Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA.

    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.04.002.

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