Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
Coxa Hospital for Joint Replacement, Tampere, Finland.
Clin Orthop Relat Res. 2021 Oct 1;479(10):2268-2280. doi: 10.1097/CORR.0000000000001793.
Mental health disorders can occur in patients with pain conditions, and there have been reports of an increased risk of persistent pain after THA and TKA among patients who have psychological distress. Persistent pain may result in the prolonged consumption of opioids and other analgesics, which may expose patients to adverse drug events and narcotic habituation or addiction. However, the degree to which preoperative use of antidepressants or benzodiazepines is associated with prolonged analgesic use after surgery is not well quantified.
QUESTION/PURPOSES: (1) Is the preoperative use of antidepressants or benzodiazepine medications associated with a greater postoperative use of opioids, NSAIDs, or acetaminophen? (2) Is the proportion of patients still using opioid analgesics 1 year after arthroplasty higher among patients who were taking antidepressants or benzodiazepine medications before surgery, after controlling for relevant confounding variables? (3) Does analgesic drug use decrease after surgery in patients with a history of antidepressant or benzodiazepine use? (4) Does the proportion of patients using antidepressants or benzodiazepines change after joint arthroplasty compared with before?
Of the 10,138 patients who underwent hip arthroplasty and the 9930 patients who underwent knee arthroplasty at Coxa Hospital for Joint Replacement, Tampere, Finland, between 2002 and 2013, those who had primary joint arthroplasty for primary osteoarthritis (64% [6502 of 10,138] of patients with hip surgery and 82% [8099 of 9930] who had knee surgery) were considered potentially eligible. After exclusion of another 8% (845 of 10,138) and 13% (1308 of 9930) of patients because they had revision or another joint arthroplasty within 2 years of the index surgery, 56% (5657 of 10,138) of patients with hip arthroplasty and 68% (6791 of 9930) of patients with knee arthroplasty were included in this retrospective registry study. Patients who filled prescriptions for antidepressants or benzodiazepines were identified from a nationwide drug prescription register, and information on the filled prescriptions for opioids (mild and strong), NSAIDs, and acetaminophen were extracted from the same database. For the analyses, subgroups were created according to the status of benzodiazepine and antidepressant use during the 6 months before surgery. First, the proportions of patients who used opioids and any analgesics (that is, opioids, NSAIDs, or acetaminophen) were calculated. Then, multivariable logistic regression adjusted with age, gender, joint, Charlson Comorbidity Index, BMI, laterality (unilateral/same-day bilateral), and preoperative analgesic use was performed to calculate odds ratios for any analgesic use and opioid use 1 year postoperatively. Additionally, the proportion of patients who used antidepressants and benzodiazepines was calculated for 2 years before and 2 years after surgery.
At 1 year postoperatively, patients with a history of antidepressant or benzodiazepine use were more likely to fill prescriptions for any analgesics than were patients without a history of antidepressant or benzodiazepine use (adjusted odds ratios 1.9 [95% confidence interval 1.6 to 2.2]; p < 0.001 and 1.8 [95% CI 1.6 to 2.0]; p < 0.001, respectively). Similarly, patients with a history of antidepressant or benzodiazepine use were more likely to fill prescriptions for opioids than patients without a history of antidepressant or benzodiazepine use (adjusted ORs 2.1 [95% CI 1.7 to 2.7]; p < 0.001 and 2.0 [95% CI 1.6 to 2.4]; p < 0.001, respectively). Nevertheless, the proportion of patients who filled any analgesic prescription was smaller 1 year after surgery than preoperatively in patients with a history of antidepressant (42% [439 of 1038] versus 55% [568 of 1038]; p < 0.001) and/or benzodiazepine use (40% [801 of 2008] versus 55% [1098 of 2008]; p < 0.001). The proportion of patients who used antidepressants and/or benzodiazepines was essentially stable during the observation period.
Surgeons should be aware of the increased risk of prolonged opioid and other analgesic use after surgery among patients who were on preoperative antidepressant and/or benzodiazepine therapy, and they should have candid discussions with patients referred for elective joint arthroplasty about this possibility. Further studies are needed to identify the most effective methods to reduce prolonged postoperative opioid use among these patients.
Level III, therapeutic study.
在患有疼痛疾病的患者中，可能会出现心理健康障碍，并且有报道称，在有心理困扰的接受全髋关节置换术（THA）和全膝关节置换术（TKA）的患者中，持续性疼痛的风险增加。持续性疼痛可能导致阿片类药物和其他镇痛药的长期使用，这可能使患者面临药物不良反应和阿片类药物滥用或成瘾的风险。然而，术前使用抗抑郁药或苯二氮䓬类药物与手术后延长镇痛药物使用的相关性尚未得到很好的量化。
问题/目的：(1) 术前使用抗抑郁药或苯二氮䓬类药物是否与术后使用阿片类药物、非甾体抗炎药或对乙酰氨基酚的比例增加有关？(2) 在控制相关混杂变量后，术前使用抗抑郁药或苯二氮䓬类药物的患者在关节置换术后 1 年仍使用阿片类镇痛药的比例是否更高？(3) 有抗抑郁药或苯二氮䓬类药物使用史的患者手术后镇痛药物的使用是否会减少？(4) 与术前相比，接受关节置换术后患者使用抗抑郁药或苯二氮䓬类药物的比例是否发生变化？
在芬兰坦佩雷考克斯医院接受髋关节置换术的 10138 例患者和接受膝关节置换术的 9930 例患者中，考虑到原发性骨关节炎（髋关节手术 64%[6502/10138]和膝关节手术 82%[8099/9930]的患者接受原发性关节置换术）的患者可能有资格接受初次关节置换术。排除另外 8%（845/10138）和 13%（1308/9930）的患者，因为他们在指数手术的 2 年内接受了翻修或另一次关节置换术，56%（5657/10138）的髋关节置换术患者和 68%（6791/9930）的膝关节置换术患者被纳入这项回顾性登记研究。从全国性药物处方登记处确定了开处方抗抑郁药或苯二氮䓬类药物的患者，并从同一数据库中提取了阿片类药物（弱效和强效）、非甾体抗炎药和对乙酰氨基酚的处方信息。在分析中，根据手术前 6 个月苯二氮䓬类药物和抗抑郁药的使用情况创建了亚组。首先，计算使用阿片类药物和任何镇痛药物（即阿片类药物、非甾体抗炎药或对乙酰氨基酚）的患者比例。然后，通过多变量逻辑回归调整年龄、性别、关节、Charlson 合并症指数、BMI、侧别（单侧/同侧双侧）和术前镇痛药物使用情况，计算术后 1 年任何镇痛药物使用和阿片类药物使用的优势比。此外，计算了手术前 2 年和手术后 2 年使用抗抑郁药和苯二氮䓬类药物的患者比例。
术后 1 年，有抗抑郁药或苯二氮䓬类药物使用史的患者比无抗抑郁药或苯二氮䓬类药物使用史的患者更有可能开处方使用任何镇痛药（调整后的优势比 1.9[95%置信区间 1.6 至 2.2]；p<0.001 和 1.8[95%置信区间 1.6 至 2.0]；p<0.001）。同样，有抗抑郁药或苯二氮䓬类药物使用史的患者比无抗抑郁药或苯二氮䓬类药物使用史的患者更有可能开处方使用阿片类药物（调整后的优势比 2.1[95%置信区间 1.7 至 2.7]；p<0.001 和 2.0[95%置信区间 1.6 至 2.4]；p<0.001）。然而，在有抗抑郁药（42%[439/1038]与 55%[568/1038]；p<0.001）和/或苯二氮䓬类药物使用史（40%[801/2008]与 55%[1098/2008]；p<0.001）的患者中，术后 1 年使用任何镇痛药物的患者比例均小于术前。有抗抑郁药和/或苯二氮䓬类药物使用史的患者比例在观察期间基本保持稳定。
外科医生应该意识到，在接受术前抗抑郁药和/或苯二氮䓬类药物治疗的患者中，手术后阿片类药物和其他镇痛药的长期使用风险增加，他们应该与接受择期关节置换术的患者进行坦诚的讨论，了解这种可能性。需要进一步研究以确定减少这些患者术后长期使用阿片类药物的最有效方法。
III 级，治疗性研究。
