Post-Op Opioid Prescribing following Total Joint Arthroplasty:An Analysis of Patient Characteristics
Qudratullah S. Qadiri, BS
In the last five years, there has been a significant decrease in the use of opioids for post-operatively pain following Total Knee arthroplasty (TKA) and Total Hip arthroplasty (THA).
Patients less than 65 years old have an increased rate of inpatient opioid use per day following both TKA and THA.
There is no significant difference between average morphine milligram equivalents (MME) per day in male or female patients.
Opioid prescribing in the United States (U.S.) has seen a substantial increase beginning in the 1990s (1,2). The U.S. Centers for Disease Control and Prevention (CDC) reported a concurrent increase in prescription opioid abuse and overdose rates (3). Unfortunately, prescription opioids were involved in over 28% of all opioid overdose deaths in 2019 (4). Among physicians, orthopedic surgeons rank as the third highest prescribing physicians accounting for 7.7% of all opioid prescriptions in the U.S. (5). Among orthopaedic procedures, Total Knee arthroplasty (TKA) and Total Hip arthroplasty (THA) are some of the most performed procedures requiring opioid pain management postoperatively. Currently, over one million total joint arthroplasties (TJA) are performed annually with numbers projected to rise over the next several decades with the aging population (6,7).
Poor care coordination contributes to multiple prescribers for the same pathology leading to an increased risk of overdose (8). Statewide prescription databases such as the Prescription Drug Monitoring Program (PDMP) have been developed to allow physicians to identify patients and prescribers more easily. These databases also prevent the phenomenon coined “doctor shopping” where patients find multiple physicians to prescribe them opioids for the same issue (9-11). Another potentially beneficial electronic tool for prescribers is Avalon AI. This service offers real-time access to analytics to help providers consider their prescribing patterns. This data may be utilized to advance artificial intelligence algorithms to better identify areas for improvement in opioid prescribing.
Many studies have assessed recent opioid prescription practices of orthopedic surgeons, but many are limited to single institutions or public insurance databases such as Medicare or Medicaid. Although these utilize large public databases, patients are limited to demographics of low socioeconomic status which reduces external validity. However, to our knowledge, no prior studies have assessed the demographic characteristics of patients with the highest prescriptions following total joint arthroplasty from a multicenter database. The purpose of this study is to identify patient characteristics and trends associated with daily morphine milligram equivalents (MME) by orthopedic surgeons in five academic institutions following primary total joint arthroplasty.
This is a retrospective, descriptive multi-center study in a consecutive series of patients who underwent primary hip and knee arthroplasty between January 2017 and February 2022. Data is collected from a conglomerate database (Avalon.ai) from five high-volume orthopaedic institutions. Records were reviewed for post-operative average morphine milligram equivalents (MME) per day to compare patient opioid use.
A total of 19,345 TJA patients were identified, 61.5% were TKA (n= 11,895), and 38.5% THA (n= 7,449) (Table 1). There is a significant decrease between average MMEs per day in 2017 and 2021 in both TKA (38.44 MME; 22.79 MME, p<0.05) and THA (32.03 MME; 27.63 MME, p<0.01) cohorts (Figure 1). There is no significant difference between the average MME opioid use per day of the TKA (30.85 MME) and THA (30.10 MME) cohorts (p>0.05) (Table 2A & 2B). There is no discrepancy between opioid use based on sex, as females received an average of 30.41 MME per day in the TKA group and males received 28.38 MME (P>0.05) (Table 3). There is also no difference based on sex in the THA group, females received 30.75 MME per day and males received 30.98 MME (p>0.05) (Table 3). Patients 65 years of age and older received significantly fewer opioids than those aged 18-44 and 45-64 in both the TKA and THA cohorts (p<0.05) (Table 3). Patients receiving outpatient TKA used an average of 24.05 MME and inpatient counterparts used 33.82 MME (p<0.05) (Table 3).
The trends for opioid use post-operatively following both TKA and THA indicate a significant decrease from 2017 to 2021 (Figure 1). This may be attributed to the increased policy aimed at reducing opioid use such as the Pennsylvania Drug Monitoring Program (PDMP) and electronic prescriptions making it easier to refill orders by eliminating the need for a follow-up appointment. Age below 65 years is associated with an increased rate of inpatient opioid use per day following both TKA and THA (Table 3). This may either be due to a physiologic change in nociceptor sensation or a difference in the generational perspective of pain. Patients received similar rates of opioids in both THA and TKA procedures (Table 2A & 2B).
Although this is a large database of patients, it is limited by the number of variables analyzed. This study is also limited to the average MME/day in the hospital. Patients often are sent home on the same day of surgery or stay for up to a few nights. This means that the MME is limited to patients' length of stay. Future studies should review smoking history, opioid naïve status, 30-day pre-op MME, 90-day post-op MME, rate of refills, race, and insurance status.
Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372(3):241-248.
Volkow ND. Prescription opioid and heroine abuse. House Committe on Energy and Commerce Subcommittee on Oversight and Investigations; 2014 April.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Policy impact: prescription painkiller overdoses. 2011 Nov. http://www.cdc.gov/drugoverdose/pdf/ policyimpact-prescriptionpainkillerod-a.pdf.
Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2020. Available at http://wonder.cdc.gov.
Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR. Characteristics of opioid prescriptions in 2009. J Am Med Assoc. 2011;305(13):1299-1301.
Williams S.N., Wolford M.L., Bercovitz A. 2000. Hospitalization for total knee replacement among inpatients aged 45 and over: United States, 2000–2010 key findings. https://www.cdc.gov/nchs/data/databriefs/db210.pdf
Wolford M.L., Palso K., Bercovitz A. 2000. Hospitalization for total hip replacement among inpatients aged 45 and over: United States, 2000–2010 key findings. https://www.cdc.gov/nchs/data/databriefs/db186.pdf
Chua K, Brummett CM, Ng S, Bohnert ASB. Association Between Receipt of Overlapping Opioid and Benzodiazepine Prescriptions From Multiple Prescribers and Overdose Risk. JAMA Netw Open. 2021;4(8):e2120353. doi:10.1001/jamanetworkopen.2021.20353
Zarling BJ, Yokhana SS, Herzog DT, Markel DC: Preoperative and postoperative opiate use by the arthroplasty patient. J Arthroplasty 2016;31:2081-2084.
Bedard NA, Pugely AJ, Westermann RW, Duchman KR, Glass NA, Callaghan JJ: Opioid use after total knee arthroplasty: Trends and risk factors for prolonged use. J Arthroplasty 2017;32:2390-2394.
Hernandez NM, Parry JA, Taunton MJ: Patients at risk: Large opioid prescriptions after total knee arthroplasty. J Arthroplasty 2017;32:2395-2398.