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    Stopping Opioids 3 Months Before Surgery Lowers the Risk of Chronic Postop Use

    With the US in the grip of an opioid epidemic, orthopaedic surgeons – among the top prescribers of opioids [1] – have been challenged to adopt strategies that help to reduce opioid usage.

    One such strategy is to taper preoperative use of opioids. Research presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons adds to the literature [2-4] showing that this strategy works: Chronic opioid users who stopped taking opioids 3 months before elective orthopaedic surgery had a reduced risk of chronic use following the procedure.

    Using an insurance company’s national claims database, the researchers identified more than 98,000 patients who had undergone 1 of 7 orthopaedic surgeries:

    • Total knee arthroplasty
    • Total hip arthroplasty
    • Total shoulder arthroplasty
    • Rotator cuff repair
    • Anterior cervical decompression and fusion
    • Posterior lumbar fusion
    • Carpal tunnel release

    From the pharmacy claims data, they were able to classify preoperative opioid use as:

    • No preoperative opioid use (opioid-naïve)
    • Less than 3 months of preoperative use
    • 3 to 6 months of preoperative use
    • More than 6 continuous months of preoperative use
    • More than 6 months of preoperative use but no prescription 3 months prior to surgery

    The researchers then looked at the number of prescriptions for opioids in the 1-year postoperative period. The primary outcome measure – chronic postoperative opioid use – was defined as 8 or more prescriptions (at least 1 prescription every 6 weeks) in the year after surgery. They also calculated total opioid usage as the number of pills per patient per day in the first postoperative year.

    In general, chronic preoperative opioid use was associated with an increased risk of postoperative chronic use. However, even chronic preoperative users who did not have a prescription filled within 3 months prior to surgery had a lower risk of chronic opioid use following surgery.

    Chronic preoperative opioid use varied by pathology. Patients who underwent posterior lumbar fusion had the highest rate of chronic use prior to surgery at 28%, while patients who had a carpal tunnel release had the lowest rate at 12%. In general, undergoing surgery led to a reduction in the use of opioids postoperatively: 42% to 62% of chronic preoperative opioid users discontinued opioids following surgery.

    “One of the most powerful findings was that when we looked at all the procedures, the group that chronically used opioids but had stopped for 3 months before surgery had a much lower chronic use of opioids postoperative,” said Dr. Frank M. Phillips, professor and director, Section of Minimally Invasive Spine Surgery, and director, Division of Spine Surgery, Rush University Medical Center in Chicago, Illinois.

    “The message to surgeons is that you should really work on getting patients off opioids for at least 3 months before surgery to significantly reduce the chance of chronic use,” Dr. Phillips added. “However, it’s not just about post-surgery addiction. The negative consequences of opioid use postop include a higher risk of infection and emergency visits, as well as a host of other adverse events.”

    Opioid use is an issue in the US, with 21% to 29% of patients who are prescribed opioids for chronic pain misusing them. [5] Although the overall opioid prescribing rate has declined since 2012, the number of opioids prescribed per person is approximately 3 times higher than in 1999. [6]

    “Sustained opioid use following surgery has become a major public health concern,” said Safdar N. Khan, MD, associate professor and chief, Division of Spine Surgery, Department of Orthopaedic Surgery, Wexner Medical Center at The Ohio State University. “We plan to utilize these findings to launch a prospective study looking at how varying opioid weaning time periods impacts chronic opioid use and short-term outcomes.”

    Source

    Brock JL, Jain N, Phillips FM, Khan SN. Orthopaedic Surgeries Decrease Chronic Opioid Use: The Relationship Between Preoperative and Postoperative Opioid Use Patterns (Poster P0369). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.

    References

    1. Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR. Characteristics of opioid prescriptions in 2009. JAMA. 2011 Apr 6;305(13):1299-301. doi: 10.1001/jama.2011.401.
    2. Nguyen LC, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplasty. 2016;31(9 Suppl):282-7. doi: 10.1016/j.arth.2016.01.068. Epub 2016 Mar 17.
    3. Kim KY, Anoushiravani AA, Chen KK, Roof M, Long WJ, Schwarzkopf R. Preoperative chronic opioid users in total knee arthroplasty-which patients persistently abuse opiates following surgery? J Arthroplasty. 2018;33(1):107-112. doi: 10.1016/j.arth.2017.07.041. Epub 2017 Aug 3.
    4. Cancienne JM, Patel KJ, Browne JA, Werner BC. Narcotic use and total knee arthroplasty. J Arthroplasty. 2018;33(1):113-118. doi: 10.1016/j.arth.2017.08.006. Epub 2017 Aug 17.
    5. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576.
    6. Centers for Disease Control and Prevention. Vital signs: changes in opioid prescribing in the United States, 2006–2015. MMWR 2017; 66(26):697-704. Accessed 1/30/19.