Department of Orthopaedic Surgery (D.B.C.R., K.N.S., E.A., E.M.C., and A.H.D.), Warren Alpert Medical School of Brown University (J.H.R. and B.H.S.), Providence, Rhode Island.
J Bone Joint Surg Am. 2021 Jan 20;103(2):106-114. doi: 10.2106/JBJS.20.00732.
The ongoing U.S. opioid epidemic threatens quality of life and poses substantial economic and safety burdens to opioid abusers and their communities, physicians, and health-care systems. Public health experts have argued that prescription opioids are implicated in this epidemic; however, opioid dosing following surgical procedures remains controversial. The purpose of this study was to evaluate the relationship between initial opioid prescribing following total hip arthroplasty (THA) and total knee arthroplasty (TKA) and the risk and quantity of long-term opioid use.
Patients undergoing THA or TKA from January 1, 2016, to June 30, 2016, were identified. Preoperative 30-day opioid and benzodiazepine exposures were evaluated using the Rhode Island Prescription Drug Monitoring Program. Cumulative morphine milligram equivalents (MMEs) in the postoperative inpatient stay, initial outpatient opioid prescription, and prescriptions filled from 31 to 90 days (prolonged use) and 91 to 150 days (chronic use) following the surgical procedure were calculated. Regression analyses evaluated the association between the initial postoperative opioid dosing and prolonged or chronic use, controlling for demographic characteristics, procedure, preoperative opioid and benzodiazepine exposures, anesthesia type, and use of a peripheral nerve block.
A total of 507 patients (198 who underwent a THA and 309 who underwent a TKA) were identified. Increased inpatient opioid dosing (odds ratio [OR], 1.49 per 1 standard deviation increase in inpatient opioid MMEs; p = 0.001) and increased dosing in the first outpatient prescription (OR, 1.26 per 1 standard deviation increase in initial outpatient prescription MMEs; p = 0.049) were each independently associated with an increased risk of prolonged opioid use. Additionally, increased inpatient dosing postoperatively was strongly associated with a greater risk of chronic use (OR, 1.77 per 1 standard deviation increase in inpatient MMEs; p < 0.001). Among the 30% (151 of 507) of patients requiring prolonged postoperative opioids, each 1-MME increase in the initial outpatient prescription dose was associated with a 0.997-MME increase in quantity filled during the prolonged period (p < 0.001). Among the 14% (73 of 507) of patients requiring chronic opioids, every 1-MME increase in the initial outpatient dose was associated with a 1.678-MME increase in chronic opioid dosing (p = 0.008).
Increased opioid dosing in the early postoperative period following total joint arthroplasty (TJA) is associated with an increased risk of extended opioid use. A dose-dependent relationship between initial outpatient dosing and greater future quantities consumed by those with prolonged usage and those with chronic usage was noted. This study suggests that providers should attempt to minimize inpatient and early outpatient opioid utilization following TJA. Multimodal pain management strategies may be employed to assist in achieving adequate pain control while minimizing opioid utilization.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
美国目前的阿片类药物泛滥危机威胁着人们的生活质量，给滥用阿片类药物的患者及其所在社区、医生和医疗保健系统带来了巨大的经济和安全负担。公共卫生专家认为，处方类阿片类药物与此类泛滥危机有关；然而，手术后的阿片类药物剂量仍存在争议。本研究旨在评估全髋关节置换术（THA）和全膝关节置换术（TKA）后初始阿片类药物处方与长期阿片类药物使用的风险和数量之间的关系。
本研究纳入了 2016 年 1 月 1 日至 6 月 30 日期间接受 THA 或 TKA 的患者。使用罗德岛州处方药物监测计划评估术前 30 天内阿片类药物和苯二氮䓬类药物的暴露情况。计算术后住院期间、初始门诊阿片类药物处方以及术后 31 至 90 天（延长使用）和 91 至 150 天（慢性使用）期间的累积吗啡毫克当量（MME）。回归分析评估了初始术后阿片类药物剂量与延长或慢性使用之间的关联，控制了人口统计学特征、手术类型、术前阿片类药物和苯二氮䓬类药物暴露、麻醉类型和周围神经阻滞的使用。
共纳入 507 例患者（198 例行 THA，309 例行 TKA）。住院期间阿片类药物剂量增加（比值比 [OR]，每增加 1 个标准偏差的住院 MME 增加 1.49；p = 0.001）和首次门诊处方剂量增加（OR，每增加 1 个标准偏差的初始门诊 MME 增加 1.26；p = 0.049）与延长阿片类药物使用的风险增加独立相关。此外，术后住院期间阿片类药物剂量增加与慢性使用风险显著增加相关（OR，每增加 1 个标准偏差的住院 MME 增加 1.77；p < 0.001）。在需要延长术后阿片类药物治疗的 30%（151 例/507 例）患者中，初始门诊处方剂量每增加 1 MME，延长期间的实际用量增加 0.997 MME（p < 0.001）。在需要慢性阿片类药物治疗的 14%（73 例/507 例）患者中，初始门诊剂量每增加 1 MME，慢性阿片类药物剂量增加 1.678 MME（p = 0.008）。
TJA 后早期术后阿片类药物剂量增加与延长阿片类药物使用的风险增加有关。延长使用和慢性使用的患者初始门诊剂量与未来消耗的更大剂量之间存在剂量依赖性关系。本研究表明，医疗保健提供者应尽量减少 TJA 后住院期间和早期门诊期间的阿片类药物使用。多模式疼痛管理策略可用于协助实现足够的疼痛控制，同时尽量减少阿片类药物的使用。
治疗性 IV 级。请参阅作者指南，以获取完整的证据等级描述。
