Preoperative Opioid Use Worsens TJA Outcomes

Total joint arthroplasty (TJA) patients taking opioids prior to surgery may have worse functional and pain outcomes, according to a new systematic review.

Opioid use to treat non-cancer pain—such as arthritis—has been on the rise, the study authors note, despite limited evidence to support this.

“Emerging evidence now suggests that opioids provide no benefit when compared to ibuprofen or acetaminophen to manage pain associated with arthritis, but had higher rates of adverse events,” the researchers reported in BMC Musculoskeletal Disorders. “Nevertheless, physician prescribing practices have resulted in over 40% of patients being prescribed opioids prior to total joint arthroplasty (TJA) in the USA.”

The review therefore sought to evaluate how preoperative opioid use impacts patient-reported outcomes (PROs) in TJA patients. The study authors queried Ovid, Embase, Cochrane Library, Scopus, Web of Science Core Collection, and CINAHL for studies comparing preoperative and postoperative PROs in total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients prescribed preoperative opioids to those without a prior prescription. The primary outcome was absolute and relative difference in PRO scores based on preoperative opioid exposure. The secondary outcomes included the prevalence of preoperative opioid use, the definition of preoperative opioid use, postoperative opioid rates based on preoperative use, and postoperative health services requirements.

The final analysis included six retrospective cohort studies with a total of 7,356 TJA patients; follow-up ranged from a mean six months to 58 months. Three studies used a matched cohort to control for confounding factors, one study used a risk adjustment, and two studies did not control for confounders. Three studies evaluated TKA patients, two studies assessed THA and TKA patients, and one study only considered THA patients.

Opioid Use Linked to Poorer Outcomes, Prolonged Use

Of the total patient cohort, 24.4% had a preoperative opioid prescription. In all six studies, these patients had worse absolute postoperative PROs. Five of the studies reported a smaller relative change in PRO score among preoperative opioid users compared to those without a preoperative prescription.

Two studies reported the mean preoperative dose in morphine equivalents per day (MED): one reported a mean 58 mg MED; the other reported that most patients had a preoperative dose of either < 30 mg MED (34%) or > 120 mg MED (34%), while 17% had a dose between 31 mg and 60 mg MED, and 15% had a dose between 61 and 120 mg MED. Preoperative use was defined differently among the studies, ranging from two years preoperatively to six weeks before surgery. Outcomes for postoperative opioid use also varied by study. One study found preoperative users consumed more opioids on postoperative days zero, one, and three, and at six weeks, while another found no significant between-group differences. Three studies found that preoperative opioid users had significantly higher long-term rates of postoperative opioid use compared to those who did not use opioids prior to surgery. Two studies analyzed postoperative health services utilization; in both studies, preoperative opioid users had a longer mean hospital length of stay, but this was only statistically significant in one report. “Although preoperative opioid use did not affect discharge destination from the surgical hospital, opioid users were more likely to be referred to chronic pain clinic postoperative when compared to preoperative opioid-naïve patients (8 patients vs. 1 patient, p < 0.001),” the study authors added.

The study authors concluded that while preoperative opioid users who undergo TJA have worse outcomes compared to opioid-naïve patients, they still benefit from the surgery.

“However, without further research that considers other patient factors in the context of preoperative opioid use, our understanding of the independent impact of opioid use on outcomes after surgery remains uncertain,” they wrote.