Many patients continue using opioids months after joint replacement

Many patients undergoing hip or knee replacement are still taking prescription opioid pain medications up to six months after surgery, reports a study in PAIN®, the official publication of the International Association for the Study of Pain® (IASP). The journal is published by Wolters Kluwer.

Led by Jenna Goesling, PhD, of the University of Michigan, the study identifies several "red flags" for persistent opioid use - particularly previous use of high-dose opioids. The results also suggest that some patients continue to use these potentially addictive pain medications despite improvement in their hip or knee pain.

Concerns about Persistent Opioid Use after Joint Replacement

Total knee and hip replacements are highly effective operations for patients with severe pain in these joints, and opioids are the main drugs used for acute pain management after such surgeries. However, little is known about long-term patterns of opioid use after joint-replacement surgery. This information is especially important as such surgeries become even more frequent as the US population ages and the "opioid epidemic" continues to produce dramatic increases in opioid use, misuse, and overdose.

Dr. Goesling and her team analyzed patterns of opioid use in 574 patients undergoing knee or hip replacement surgery (arthroplasty). Patients were followed up at one, three, and six months after surgery to assess rates of and risk factors for long-term opioid use.

About 30 percent of the patients were taking opioids prior to their joint replacement surgery. Of this group, 53 percent of knee-replacement patients and 35 percent of hip replacement patients were still taking opioids at six months after surgery.

Patients who were not taking opioids prior to surgery were less likely to report persistent opioid use: About 8 percent in the knee-replacement group and 4 percent in the hip-replacement group continued to take opioids at the six-month follow up. Although these are relatively small percentages, this suggests that a portion of patients who were "opioid naïve" prior to surgery will become new chronic opioid users following arthroplasty.

The strongest predictor of long-term opioid use was taking high-dose opioids before joint replacement surgery. For patients in the highest preoperative dose group (equivalent to more than 60 milligrams of oral morphine per day), the predicted probability of persistent opioid use at six months was 80 percent.

Among patients not previously taking opioids, those with higher pain scores the day of surgery - both in the affected joint and overall body pain - were more likely to report persistent opioid use at six months. Opioid use was also more likely for patients who scored higher on a measure of pain catastrophizing - exaggerated responses and worries about pain - than those with depressive symptoms.

For all patients, reductions in overall body pain were associated with decreased odds of being on opioids at six months. However, improvement in knee or hip pain after joint replacement did not reduce the likelihood of long-term opioid use.

Persistent opioid use after knee or hip replacement surgery may be more common than previously reported, the new results suggest. Importantly, continued opioid use is not necessarily related to pain in the affected joint. "We hypothesize that the reasons patients continue to use opioids may be due to pain in other areas, self-medicating affective distress, and therapeutic opioid dependence," the researchers write.

Dr. Goesling and coauthors discuss the implications for short-term and long-term pain management for patients undergoing joint replacement surgery. They add, "A long-term goal includes the development of interventions to aid physicians and patients with opioid cessation following surgical interventions" such as hip and knee replacement.

Article: Trends and predictors of opioid use after total knee and total hip arthroplasty, Goesling, Jenna; Moser, Stephanie E.; Zaidi, Bilal; Hassett, Afton L.; Hilliard, Paul; Hallstrom, Brian; Clauw, Daniel J.; Brummett, Chad M., PAIN, doi: 10.1097/j.pain.0000000000000516, published June 2016.