The Opioid Crisis: Have Prescribing Habits Changed for Pain Control in Joint Arthroplasty?

An analysis explored changes in postoperative opioid prescriptions for total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients over a three-year period.

“Potential overprescribing of opioids after surgery may contribute to opioid-related adverse events. The proportion of opioid-naive patients with a new opioid prescription within 7 days after total knee arthroplasty (TKA) increased from 79.1% in 2004 to 82.0% in 2012,” the study authors explained. In light of the opioid crisis, measures were put into place by federal agencies and at the state level to reduce opioid overprescribing, but it remains unknown what effect these changes had on prescribing trends.

To assess changes in prescribing patterns from 2014–2017, the researchers queried the Optum deidentified electronic health record dataset, housing data on more than 90 million patients from 38 hospital networks and 18 nonnetwork hospitals in the U.S. Patients who underwent TKA or THA during the study period in the hospital networks were evaluated or opioid prescriptions from discharge to 60 days post-discharge; for patients receiving opioid prescriptions, the total morphine milligram equivalent (MME) dose was determined. The pain level at discharge was determined using a mean pain score for all observations on the day nearest to discharge, with the same formula used to determine pain levels within two months following discharge at days seven to 14, 15 to 21, 22 to 29, 30 to 44, and 45 to 60.

A total of 236,631 joint arthroplasty patients were identified: 86,058 THA patients (mean age at surgery, 64.48 years) and 150,573 TKA patients (mean age at surgery, 65.99 years). Most patients were female (n=139,410; 58.9%). Over the study period, the proportion of TKA patients who received an opioid prescription within 60 days of discharge increased from 81.9% to 91.5%; for THA patients, it increased from 82.0% to 89.7%. From 2014 to 2015, an increase in the mean MME prescribed during the 60-day post-discharge period was observed in both groups; the mean remained stable from 2015 to 2016 and decreased from 2016 to 2017. No significant differences were observed in the mean (SD) level of pain at discharge after THA in 2014 (3.28 [2.02]), 2015 (3.43 [1.96]), 2016 (3.51 [1.94]), or 2017 (3.42 [1.92]) or after TKA in 2014 (3.73 [2.02]), 2015 (3.87 [1.97]), 2016 (3.90 [1.94]), or 2017 (390 [1.96]). Over the study period, the postoperative pain trajectory from seven to 14 days to 45 to 60 days post-discharged did not significantly differ between THA and TKA.

Factors associated with higher odds of receiving at least one opioid prescription within 60 days post-discharge among THA patients included a more recent year of surgery, higher pain score at discharge, insurance with Medicare only, and insurance with Medicaid only, while predictors of lower odds of a prescription included older age, African American race, and Hispanic ethnicity. Similar correlations were observed for TKA patients.

The study was published in JAMA Network Open.

“These findings suggest that the outcomes of policies aimed at curbing postoperative opioid overprescribing after THA and TKA may be limited. Our findings underscore the need to monitor effectiveness of policies in the real-world setting, given the substantial amount of resources devoted to their implementations,” the study authors concluded.