1Midwest Orthopaedics at Rush, Rush University, Chicago, Illinois 2HSS Sports Medicine Institute West Side, Hospital for Special Surgery, New York, NY 3Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.
JBJS Rev. 2020 Jun;8(6):e0154. doi: 10.2106/JBJS.RVW.19.00154.
The purpose of this comprehensive review was to investigate risk factors associated with prolonged opioid use after orthopaedic procedures. A comprehensive review of the opioid literature may help to better guide preoperative management of expectations as well as opioid-prescribing practices.
A systematic review of all studies pertaining to opioid use in relation to orthopaedic procedures was conducted using the MEDLINE, Embase, and CINAHL databases. Data from studies reporting on postoperative opioid use at various time points were collected. Opioid use and risk of prolonged opioid use were subcategorized by subspecialty, and aggregate data for each category were calculated.
There were a total of 1,445 eligible studies, of which 45 met inclusion criteria. Subspecialties included joint arthroplasty, spine, trauma, sports, and hand surgery. A total of 458,993 patients were included, including 353,330 (77%) prolonged postoperative opioid users and 105,663 (23%) non-opioid users. Factors associated with prolonged postoperative opioid use among all evaluated studies included body mass index (BMI) of ≥40 kg/m (relative risk [RR], 1.06 to 2.32), prior substance abuse (RR, 1.08 to 3.59), prior use of other medications (RR, 1.01 to 1.46), psychiatric comorbidities (RR, 1.08 to 1.54), and chronic pain conditions including chronic back pain (RR, 1.01 to 10.90), fibromyalgia (RR, 1.01 to 2.30), and migraines (RR, 1.01 to 5.11). Age cohorts associated with a decreased risk of prolonged postoperative opioid use were those ≥31 years of age for hand procedures (RR, 0.47 to 0.94), ≥50 years of age for total hip arthroplasty (RR, 0.70 to 0.80), and ≥70 years of age for total knee arthroplasty (RR, 0.40 to 0.80). Age cohorts associated with an increased risk of prolonged postoperative opioid use were those ≥50 years of age for sports procedures (RR, 1.11 to 2.57) or total shoulder arthroplasty (RR, 1.26 to 1.40) and those ≥70 years of age for spine procedures (RR, 1.61). Identified risk factors for postoperative use were similar across subspecialties.
We provide a comprehensive review of the various preoperative and postoperative risk factors associated with prolonged opioid use after elective and nonelective orthopaedic procedures. Increased BMI, prior substance abuse, psychiatric comorbidities, and chronic pain conditions were most commonly associated with prolonged postoperative opioid use. Careful consideration of elective surgical intervention for painful conditions and perioperative identification of risk factors within each patient's biopsychosocial context will be essential for future modulation of physician opioid-prescribing patterns.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
本综述的目的是研究与骨科手术后长期使用阿片类药物相关的风险因素。对阿片类药物文献的全面回顾可能有助于更好地指导术前管理预期以及开阿片类药物的实践。
使用 MEDLINE、Embase 和 CINAHL 数据库对所有与骨科手术中阿片类药物使用相关的研究进行了系统综述。收集了报告不同时间点术后阿片类药物使用情况的研究数据。按亚专科对阿片类药物使用和延长阿片类药物使用的风险进行了分类，并计算了每个类别的汇总数据。
共有 1445 项符合条件的研究，其中 45 项符合纳入标准。亚专科包括关节置换术、脊柱、创伤、运动和手部手术。共有 458993 名患者纳入研究，其中 353330 名（77%）患者术后长期使用阿片类药物，105663 名（23%）患者未使用阿片类药物。所有评估研究中与术后长期使用阿片类药物相关的因素包括 BMI 大于等于 40kg/m²（相对风险 [RR]，1.06 至 2.32）、既往药物滥用（RR，1.08 至 3.59）、既往使用其他药物（RR，1.01 至 1.46）、精神合并症（RR，1.08 至 1.54）以及慢性疼痛疾病，包括慢性背痛（RR，1.01 至 10.90）、纤维肌痛（RR，1.01 至 2.30）和偏头痛（RR，1.01 至 5.11）。与术后长期使用阿片类药物风险降低相关的年龄组包括手部手术年龄大于等于 31 岁（RR，0.47 至 0.94）、全髋关节置换术年龄大于等于 50 岁（RR，0.70 至 0.80）和全膝关节置换术年龄大于等于 70 岁（RR，0.40 至 0.80）。与术后长期使用阿片类药物风险增加相关的年龄组包括运动程序中年龄大于等于 50 岁（RR，1.11 至 2.57）或全肩关节置换术（RR，1.26 至 1.40）以及脊柱手术中年龄大于等于 70 岁（RR，1.61）。术后使用的风险因素在各亚专科中相似。
我们对与择期和非择期骨科手术后长期使用阿片类药物相关的各种术前和术后风险因素进行了全面综述。BMI 增加、既往药物滥用、精神合并症和慢性疼痛疾病与术后长期使用阿片类药物最相关。在每个患者的生物心理社会背景下仔细考虑对疼痛疾病进行择期手术干预以及围手术期识别风险因素，对于未来调整医生开具阿片类药物的模式至关重要。
预后 IV 级。请参阅《作者说明》以获取完整的证据水平描述。
