Department of Orthopaedic Surgery, University of California, San Francisco, CA; Orthopaedic Section, San Francisco Veterans Affairs Medical Center, San Francisco, CA.
Department of Anesthesiology, Duke University Medical Center, Durham, NC; The Patient Safety Center of Inquiry, Durham Veterans Affairs Medical Center, Durham, NC.
J Arthroplasty. 2019 May;34(5):893-897. doi: 10.1016/j.arth.2019.01.054. Epub 2019 Jan 29.
In the United States, opioids are commonly prescribed to treat knee pain after total knee arthroplasty (TKA). While surgery leads to decreased pain in most patients, a sizable minority continue to experience severe pain and consume opioids chronically after TKA. We sought to determine the population-level effect of TKA on opioid consumption by detailing the pattern of opioid prescriptions before and after surgery.
We retrospectively identified US Veterans Health Administration TKA patients from 2010 to 2015. Outpatient opioid prescriptions were identified from 18 months before to 18 months after surgery, and mean daily opioid doses were calculated. Our primary end point was the achievement of opioid-freedom, defined as a period of at least 6 months without opioids. We compared the percentage of patients who were opioid-free preoperatively to the percentage who were opioid-free 18 months after surgery (no prescriptions after postoperative month 12). We identified factors associated with opioid-freedom.
In a cohort of 33,927 patients, 41% were opioid-free in the month before surgery compared to 54% 18 months after surgery (P < .001). Preoperative freedom from opioids (odds ratio, 4.59; 95% confidence interval, 4.34 to 4.85; P < .001) was more strongly associated with postoperative freedom from opioids than patient medical and social factors.
TKA was associated with an increase in postoperative freedom from opioids. Low preoperative dose of opioids was more strongly associated with postoperative opioid-freedom than patient characteristics, suggesting that opioid prescription patterns are a chief driver of opioid use after surgery.
Retrospective cohort study.
在美国，阿片类药物常用于治疗全膝关节置换术（TKA）后的膝关节疼痛。虽然手术能使大多数患者的疼痛减轻，但仍有相当一部分患者在 TKA 后持续出现严重疼痛并长期使用阿片类药物。我们旨在通过详细描述手术前后阿片类药物处方的模式来确定 TKA 对阿片类药物消耗的人群水平效应。
我们从 2010 年至 2015 年回顾性地确定了美国退伍军人健康管理局 TKA 患者。从手术前 18 个月到手术后 18 个月，我们确定了门诊阿片类药物处方，并计算了平均每日阿片类药物剂量。我们的主要终点是实现无阿片类药物状态，定义为至少 6 个月没有阿片类药物的时期。我们比较了术前无阿片类药物患者的百分比与术后 18 个月（术后第 12 个月后无处方）无阿片类药物患者的百分比。我们确定了与无阿片类药物状态相关的因素。
在 33927 例患者的队列中，41%的患者在手术前一个月没有使用阿片类药物，而 18 个月后有 54%的患者没有使用阿片类药物（P<0.001）。术前无阿片类药物（优势比，4.59；95%置信区间，4.34 至 4.85；P<0.001）与术后无阿片类药物的相关性强于患者的医疗和社会因素。
TKA 与术后无阿片类药物的增加相关。术前低剂量阿片类药物与术后无阿片类药物的相关性强于患者特征，表明阿片类药物处方模式是术后阿片类药物使用的主要驱动因素。
证据水平 III：回顾性队列研究。
