Anthony Chris A, Westermann Robert W, Bedard Nicholas, Glass Natalie, Bollier Matt, Hettrich Carolyn M, Wolf Brian R
Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
Am J Sports Med. 2017 Nov;45(13):3098-3103. doi: 10.1177/0363546517719226. Epub 2017 Aug 14.
Surgeons and health care systems have received a call to action in an effort to curtail the current opioid epidemic.
To (1) define the natural history of opioid demand after anterior cruciate ligament reconstruction (ACLR), (2) consider how filling preoperative opioid prescriptions affects opioid demand after ACLR, and (3) evaluate the effect of additional procedures during ACLR and patient age on postoperative opioid demand.
Cohort study; Level of evidence, 3.
ACLRs performed in the Humana database between 2007 and 2014 were identified using Current Procedural Terminology code 29888. Patients were considered preoperative opioid users if they had filled an opioid prescription in the 3 months preceding surgery. Patients were defined as "chronic" opioid users if they had filled a prescription preoperatively at 1 to 3 months from surgery. Further categorization was performed by identifying patients who only underwent ACLR with no other procedures, those who underwent ACLR with meniscus repair, those who underwent ACLR with meniscectomy, and those who underwent ACLR with microfracture. Categorization by age was also performed. The relative risk (RR) of postoperative opioid use was calculated, and 95% CIs were determined.
Over the course of the study period, 4946 ACLRs were performed. At 3 months after their procedure, 7.24% of patients were still filling opioid prescriptions. At 9 and 12 months postoperatively, 4.97% and 4.71% of patients, respectively, were still filling opioid prescriptions. Nearly 35% of patients (1716/4946) were filling opioid pain prescriptions in the 3 months before ACLR. Those filling preoperative opioid prescriptions were 5.35 (95% CI, 4.15-6.90) times more likely to be filling opioid prescriptions at 3 months after ACLR than nonusers (15.38% vs 2.88%, respectively). Those filling opioid prescriptions chronically before surgery were at a 10.50 (95% CI, 7.53-14.64) times increased risk of filling postoperative opioid prescriptions at 5 months. At 5 months postoperatively, patients undergoing ACLR with microfracture had a 1.96 (95% CI, 1.34-2.87) increased risk of filling opioid prescriptions compared with ACLR alone, 2.38 (95% CI, 1.48-3.82) increased risk compared with ACLR with meniscus repair, and 1.51 (95% CI, 1.04-2.19) increased risk compared with ACLR with meniscectomy. Patients younger than 25 years of age had an increased risk of filling opioid prescriptions after ACLR at all time points of the study.
Opioid demand after ACLR dropped significantly in the vast majority of patients by the third postoperative month. Surprisingly, 35% of patients undergoing ACLR were observed to be using opioid medication preoperatively, and this study found preoperative opioid use to be a strong predictor of postoperative opioid demand with a 5- to 7-fold increased risk in this patient population. Patients who were filling opioid prescriptions 1 to 3 months from their surgical date were at the highest risk for postoperative opioid utilization. Patients undergoing ACLR with microfracture were at an increased risk of filling opioid prescriptions. Patients less than 25 years of age were at an elevated risk of filling opioid prescriptions at all time points postoperatively.
外科医生和医疗保健系统已接到行动呼吁，以努力遏制当前的阿片类药物流行。
（1）确定前交叉韧带重建（ACLR）后阿片类药物需求的自然史，（2）考虑术前开具阿片类药物处方如何影响ACLR后的阿片类药物需求，以及（3）评估ACLR期间的额外手术和患者年龄对术后阿片类药物需求的影响。
队列研究；证据等级，3级。
使用当前手术操作术语代码29888识别2007年至2014年期间在Humana数据库中进行的ACLR。如果患者在手术前3个月内开具过阿片类药物处方，则被视为术前阿片类药物使用者。如果患者在手术前1至3个月内开具过处方，则被定义为“慢性”阿片类药物使用者。通过识别仅接受ACLR而无其他手术的患者、接受ACLR并半月板修复的患者、接受ACLR并半月板切除术的患者以及接受ACLR并微骨折的患者进行进一步分类。也按年龄进行分类。计算术后使用阿片类药物的相对风险（RR），并确定95%置信区间（CI）。
在研究期间，共进行了4946例ACLR。术后3个月时，7.24%的患者仍在开具阿片类药物处方。术后9个月和12个月时，分别有4.97%和4.71%的患者仍在开具阿片类药物处方。近35%的患者（1716/4946）在ACLR前3个月内开具阿片类药物止痛处方。术前开具阿片类药物处方的患者在ACLR后3个月开具阿片类药物处方的可能性是非使用者的5.35倍（95%CI，4.15 - 6.90）（分别为15.38%和2.88%）。术前长期开具阿片类药物处方的患者在术后5个月开具术后阿片类药物处方的风险增加10.50倍（95%CI，7.53 - 14.64）。术后5个月时，接受ACLR并微骨折的患者开具阿片类药物处方的风险比单纯ACLR增加1.96倍（95%CI，1.34 - 2.87），比接受ACLR并半月板修复增加2.38倍（95%CI，1.48 - 3.82），比接受ACLR并半月板切除术增加1.51倍（95%CI，1.04 - 2.19）。年龄小于25岁的患者在研究的所有时间点ACLR后开具阿片类药物处方的风险均增加。
绝大多数患者在术后第三个月ACLR后的阿片类药物需求显著下降。令人惊讶的是，观察到35%接受ACLR的患者术前使用阿片类药物，本研究发现术前使用阿片类药物是术后阿片类药物需求的有力预测因素，该患者群体的风险增加5至7倍。手术日期前1至3个月开具阿片类药物处方的患者术后使用阿片类药物的风险最高。接受ACLR并微骨折的患者开具阿片类药物处方的风险增加。年龄小于25岁的患者在术后所有时间点开具阿片类药物处方的风险均升高。
