scholarly journals β-blocker Use is Associated with a Reduction in Opioid Use 30 Days After Total Knee Arthroplasty

2019 ◽  
Vol 5 (22;5) ◽  
pp. E395-E406
Author(s):  
Jordan Starr
Keyword(s):  
Total Knee Arthroplasty ◽  
Oral Morphine ◽  
Veterans Affairs ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Total Knee ◽  
Β Blocker ◽  
Β Blockers ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

Background: Total knee arthroplasty (TKA) can lead to chronic pain and prolonged postoperative opioid use. There are few evidence-based interventions to prevent these outcomes. Recently, β-blockers have emerged as possible novel analgesics. Objectives: The objective of this study was to determine whether perioperative β-blocker use is associated with reduced prolonged postoperative opioid use after TKA. Study Design: This study used a retrospective cohort design. Setting: The research took place within Department of Veterans Affairs hospitals in the United States between April 2012 and April 2016. Methods: Patients: IRB approval was obtained to examine the records of Veterans Affairs (VA) patients undergoing TKA. Patients using opioids 60 days before surgery were excluded. Intervention: The intervention being investigated was perioperative β-blocker use, overall and by class. Measurement: Oral morphine equivalent usage through postoperative day 1 and prescription opioid refills through 30, 90, and 365 days after TKA were recorded. Adjusted models were created controlling for relevant demographic and comorbidity covariates. A secondary analysis examined the same outcomes separated by β-blocker class. Results: The cohort was 93.8% male with a mean age of 66 years. Among the 11,614 TKAs that comprised the cohort, 2,604 (22.4%) were performed on patients using β-blockers. After adjustment, β-blocker use was associated with reduced opioid use through 30 days after surgery (odds ratio [OR] 0.89 [95% confidence interval (CI), 0.80-0.99], P = .026). Selective β-blockers were associated with reduced opioid use at 30 days (OR 0.88 [95% CI, 0.78-0.98], P = .021), and nonselective β-blockers were associated with reduced oral morphine equivalent usage through postoperative day 1 (β = -17.9 [95% CI, -29.9 to -5.8], P = .004). Limitations: Generalizability of these findings is uncertain, because this study was performed on a cohort of predominantly white, male VA patients. This study also measured opioid use, but opioid use is not a perfect surrogate for pain. Nevertheless, opioid use offers value as an objective measure of pain persistence in a national cohort for which patient-reported outcomes are otherwise unavailable. Conclusions: Perioperative β-blocker use was associated with reduced prescription opioid use at 30 days after surgery. Both selective and nonselective β-blockers were associated with reduced opioid use when analyzed individually. Key words: Analgesics, opioid, arthroplasty, replacement, knee, adrenergic beta-antagonists, pain management

scholarly journals Safety of benzodiazepines and opioids in interstitial lung disease: a national prospective study

2018 ◽  
Vol 52 (6) ◽  
pp. 1801278 ◽  
Author(s):  
Sabrina Bajwah ◽  
Joanna M. Davies ◽  
Hanan Tanash ◽  
David C. Currow ◽  
Adejoke O. Oluyase ◽  
...  
Keyword(s):  
Interstitial Lung Disease ◽  
Lung Disease ◽  
Low Dose ◽  
Cox Regression ◽  
Oral Morphine ◽  
High Dose ◽  
Opioid Use ◽  
Respiratory Compromise ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

Safety concerns are a barrier to prescribing benzodiazepines (BDZs) and opioids in interstitial lung disease (ILD). We therefore examined the association of BDZs and opioids on risk of admission to hospital and death.We conducted a population-based longitudinal cohort study of fibrotic ILD patients starting long-term oxygen therapy in Sweden between October 2005 and December 2014. Effects of BDZs and opioids on rates of admission to hospital and mortality were analysed using Fine–Gray and Cox regression while adjusting for potential confounders.We included 1603 patients (61% females). BDZs were used by 196 (12%) patients and opioids were used by 254 (15%) patients. There was no association between BDZs and increased admission. Treatment with high- versus low-dose BDZs was associated with increased mortality (subdistribution hazard ratio (SHR) 1.46, 95% CI 1.08–1.98 versus 1.13, 95% CI 0.92–1.38). Opioids showed no association with increased admission. Neither low-dose opioids (≤30 mg·day−1 oral morphine equivalent) (SHR 1.18, 95% CI 0.96–1.45) nor high-dose opioids (>30 mg·day−1 oral morphine equivalent) (SHR 1.11, 95% CI 0.89–1.39) showed association with increased mortality.This first ever study to examine associations between BDZ and opioid use and harm in ILD supports the use of opioids and low-dose BDZs in severely ill patients with respiratory compromise.

Identifying Patterns and Predictors of Prescription Opioid Use After Total Joint Arthroplasty

2021 ◽  
Author(s):  
Muhammad Ali Chaudhary ◽  
Michael K Dalton ◽  
Tracey P Koehlmoos ◽  
Andrew J Schoenfeld ◽  
Eric Goralnick
Keyword(s):  
Total Knee Arthroplasty ◽  
Total Hip Arthroplasty ◽  
Knee Arthroplasty ◽  
Surgical Intervention ◽  
Joint Arthroplasty ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Factors Associated ◽  
Total Knee ◽  
Prescription Opioid Use

ABSTRACT Introduction Total hip arthroplasty and total knee arthroplasty account for over 1 million procedures annually. Opioids are the mainstay of postoperative pain management for these patients. In this context, the objective of this study was to determine patterns of use and factors associated with early discontinuation of opioids after total joint arthroplasty (TJA). Methods TRICARE claims data (2006-2014) were queried for adult (18-64 years) patients who underwent total hip arthroplasty or total knee arthroplasty. Prescription opioid use was identified from 6 months before and 6 months after surgical intervention. Prior opioid use was categorized as naïve, exposed (with non-sustained use), and sustained (6 month continuous use before surgery). Cox proportional-hazards models were used to identify factors associated with opioid discontinuation following TJA. Results Among the 29,767 patients included in the study, 15,271 (51.3%) had prior opioid exposure and 3,740 (12.5%) were sustained opioid users. At 6 months after the surgical intervention, 3,171 (10.6%) continued opioid use, 3.3% were among opioid naïve, 10.2% among exposed, and 33.3% among sustained users. In risk-adjusted models, prior opioid exposure (hazards ratio: 0.65, 95% CI: 0.62-0.67) and sustained prior use (hazards ratio: 0.33, 95% CI: 0.31-0.35) were the strongest predictors of lower likelihood of opioid discontinuation. Lower socio-economic status, depression, and anxiety were also strong predictors. Conclusion Prior opioid exposure was strongly associated with continued opioid dependence after TJA. Although one-third of prior sustained users continued use after surgery, approximately 10% of previously exposed patients became sustained users, making them the prime candidates for targeted interventions to reduce the likelihood of sustained opioid use after TJA.

scholarly journals Impact of Preoperative Opioid Use on Patient-Reported Outcomes after Revision Total Knee Arthroplasty: A Propensity Matched Analysis

2021 ◽  
Author(s):  
Eitan Ingall ◽  
Christian Klemt ◽  
Christopher M. Melnic ◽  
Wayne B. Cohen-Levy ◽  
Venkatsaiakhil Tirumala ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Propensity Score ◽  
Knee Arthroplasty ◽  
Patient Reported Outcomes ◽  
Opioid Use ◽  
Absolute Increase ◽  
Patient Reported ◽  
Total Knee ◽  
Opioid Users ◽  
Revision Tka

AbstractThis is a retrospective study. Prior studies have characterized the deleterious effects of narcotic use in patients undergoing primary total knee arthroplasty (TKA). While there is an increasing revision arthroplasty burden, data on the effect of narcotic use in the revision surgery setting remain limited. Our aim was to characterize the effect of active narcotic use at the time of revision TKA on patient-reported outcome measures (PROMs). A total of 330 consecutive patients who underwent revision TKA and completed both pre- and postoperative PROMs was identified. Due to differences in baseline characteristics, 99 opioid users were matched to 198 nonusers using the nearest-neighbor propensity score matching. Pre- and postoperative knee disability and osteoarthritis outcome score physical function (KOOS-PS), patient reported outcomes measurement information system short form (PROMIS SF) physical, PROMIS SF mental, and physical SF 10A scores were evaluated. Opioid use was identified by the medication reconciliation on the day of surgery. Propensity score–matched opioid users had significantly lower preoperative PROMs than the nonuser for KOOS-PS (45.2 vs. 53.8, p < 0.01), PROMIS SF physical (37.2 vs. 42.5, p < 0.01), PROMIS SF mental (44.2 vs. 51.3, p < 0.01), and physical SF 10A (34.1 vs. 36.8, p < 0.01). Postoperatively, opioid-users demonstrated significantly lower scores across all PROMs: KOOS-PS (59.2 vs. 67.2, p < 0.001), PROMIS SF physical (43.2 vs. 52.4, p < 0.001), PROMIS SF mental (47.5 vs. 58.9, p < 0.001), and physical SF 10A (40.5 vs. 49.4, p < 0.001). Propensity score–matched opioid-users demonstrated a significantly smaller absolute increase in scores for PROMIS SF Physical (p = 0.03) and Physical SF 10A (p < 0.01), as well as an increased hospital length of stay (p = 0.04). Patients who are actively taking opioids at the time of revision TKA report significantly lower preoperative and postoperative outcome scores. These patients are more likely to have longer hospital stays. The apparent negative effect on patient reported outcomes after revision TKA provides clinically useful data for surgeons in engaging patients in a preoperative counseling regarding narcotic use prior to revision TKA to optimize outcomes.

Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients

Pain Medicine ◽  
2019 ◽  
Vol 21 (3) ◽  
pp. 595-603 ◽  
Author(s):  
Seshadri C Mudumbai ◽  
Paul Chung ◽  
Nick Nguyen ◽  
Brooke Harris ◽  
J David Clark ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Hospital Readmission ◽  
Veterans Health Administration ◽  
Care Utilization ◽  
Veterans Health ◽  
Day Hospital ◽  
Health Administration ◽  
Opioid Use ◽  
Short Acting ◽  
Total Knee

Abstract Objective Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization? Methods We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010–September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed. Results The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14–1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants. Conclusions Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

scholarly journals OP0088 INITIATING TNF INHIBITORS IN INFLAMMATORY ARTHRITIS DOES NOT DECREASE THE AVERAGE OPIOID ANALGESIC CONSUMPTION

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 58.2-59
Author(s):  
O. Palsson ◽  
T. Love ◽  
J. K. Wallman ◽  
M. C. Kapetanovic ◽  
P. S. Gunnarsson ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Psoriatic Arthritis ◽  
Inflammatory Arthritis ◽  
Opioid Analgesic ◽  
Oral Morphine ◽  
Undifferentiated Arthritis ◽  
First Line ◽  
The Mean ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

Background:TNFα-inhibitor (TNFi) therapy is effective in controlling several rheumatic diseases and has been shown to reduce pain in patients with arthritis. Opioids are often prescribed for chronic pain, a common issue in inflammatory joint disease.Objectives:To explore the impact of the initiation of TNFi therapy as a first-line biologic disease-modifying anti-rheumatic drug (DMARD) on the prescription rates of opioids in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and undifferentiated arthritis (UA) in Iceland.Methods:All patients receiving biologic DMARD therapy for rheumatic diseases in Iceland are registered in a nationwide database (ICEBIO). The Icelandic Directorate of Health operates a Prescription Medicines Register that includes over 90% of all drug prescriptions in Iceland. The study group included patients with RA, PsA, AS, and UA registered in ICEBIO and for each of them five randomly selected comparators from the general population matched on age, sex, and calendar time. On February 1st2016 we extracted data on all filled opioid analgesic prescriptions two years before and two years after the date of TNFi initiation.Results:Data from 359 RA, 217 AS, 251 PsA and 113 UA patients and 4700 comparators were collected. In total, 75% of patients compared to 43% of comparators received ≥1 opiate prescription during the study period. The proportion of patients using opioids (regardless of dose) two years prior to TNFi initiation was 41%, increasing to 49% the following year. After TNFi initiation the proportion returned to 40% (Figure 1). Despite this, the mean yearly opiate dose used by the patients followed a rising trajectory throughout the study period (Figure 2). In total, patients were prescribed nearly 6 times more opioids than the comparators, corresponding to a bootstrapped mean (95% CI) dose of 818 (601-1073) mg MED per patient and year compared to 139 (111-171) mg for comparators.Figure 1.Percental distributions of opioid analgesic use by dose (according to dispensed prescriptions) among patients with inflammatory arthritis (A) and matched comparators (B). All doses are oral morphine equivalent dose (MED) in milligrams.Figure 2.Bootstrapped mean oral morphine equivalent dose per person per year for patients with inflammatory arthritis (above) and age and sex matched comparators (below). Box edges represent 25-75thpercentiles and whiskers 95% confidence intervals.Conclusion:Three out of four patients with inflammatory arthritis in Iceland use opioid analgesics in the two years prior to and/or after the initiation of TNFi therapy and the mean doses were significantly higher than in matched comparators. The proportion of patients receiving opioids increased before TNFi therapy and then decreased again to the previous level. The initiation of the first-line TNFi did not reduce opioid consumption by dose at the group level. On the contrary, there was a trend towards increasing doses over time in both patients and comparators, possibly reflecting the development of opiate tolerance.Table 1.Baseline demographic data. Mean ± SD unless specified. * defined from diagnosis to baselAll patientsRheumatoid arthritisPsoriatic arthritisAnkylosing spondylitisUndifferentiated arthritisTotal n (%)940 (100)359 (38)251 (27)217 (23)113 (12)Age (years)49 ± 1453 ± 1449 ± 1343 ± 1344 ± 15Disease duration (years)*7.8 ± 8.58.2 ± 8.27.4 ± 7.88.3 ± 10.26.3 ± 6.6Female58%73%59%34%52%Disclosure of Interests:Olafur Palsson: None declared, Thorvardur Love: None declared, Johan K Wallman Consultant of: Consultant for AbbVie, Celgene, Eli Lilly, Novartis and UCB Pharma., Meliha C Kapetanovic: None declared, Petur S Gunnarsson: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen

scholarly journals Reduction in opioid use with perioperative non-pharmacologic analgesia in total knee arthroplasty and ACL reconstruction: a systematic review

SICOT-J ◽  
2021 ◽  
Vol 7 ◽  
pp. 63
Author(s):  
Ryan B Juncker ◽  
Faisal M Mirza ◽  
Joel J Gagnier
Keyword(s):  
Systematic Review ◽  
Total Knee Arthroplasty ◽  
Acl Reconstruction ◽  
Knee Arthroplasty ◽  
Cruciate Ligament ◽  
Future Research ◽  
Opioid Epidemic ◽  
Clinical Implementation ◽  
Opioid Use ◽  
Total Knee

Introduction: The world’s opioid epidemic has gotten increasingly severe over the last several decades and projects to continue worsening. Orthopedic surgery is the largest contributor to this epidemic, accounting for 8.8% of postoperative opioid dependence cases. Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction are commonly performed orthopedic operations heavily reliant on opioids as the primary analgesic in the peri- and immediate postoperative period. These downfalls highlight the pressing need for an alternate, non-pharmacologic analgesic to reduce postoperative opioid use in orthopedic patients. The presented systematic review aimed to analyze and compare the most promising non-pharmacologic analgesic interventions in the available literature to guide future research in such a novel field. Methods: A systematic search of PubMed, MEDLINE, Embase, Cochrane, and Web of Science was performed for studies published before July 2020 based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, and the obtained manuscripts were evaluated for inclusion or exclusion against strict, pre-determined criteria. Risk-of-bias and GRADE (grades of recommendation, assessment, development, and evaluation) assessments were then performed on all included studies. Results: Six studies were deemed fit for inclusion, investigating three non-pharmacologic analgesics: percutaneous peripheral nerve stimulation, cryoneurolysis, and auricular acupressure. All three successfully reduced postoperative opioid use while simultaneously maintaining the safety and efficacy of the procedure. Discussion: The results indicate that all three presented non-pharmacologic analgesic interventions are viable and warrant future research. That said, because of its slight advantages in postoperative pain control and operational outcomes, cryoneurolysis seems to be the most promising. Further research and eventual clinical implementation of these analgesics is not only warranted but should be a priority because of their vast potential to reduce orthopedics surgeries’ contribution to the opioid epidemic.

scholarly journals A Collaborative Approach to Pain Control Reduces In-hospital Opioid Use and Improves Range of Motion following Total Knee Arthroplasty

Cureus ◽  
2019 ◽  
Author(s):  
Christopher Roberts ◽  
Devon Foster ◽  
Glen G Shi ◽  
Elizabeth R Lesser ◽  
Michael G Heckman ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Range Of Motion ◽  
Knee Arthroplasty ◽  
Pain Control ◽  
Collaborative Approach ◽  
Opioid Use ◽  
Total Knee
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