Why Non Opioid Pain Medicine is More Important than Ever

The Link Between Opioid Use Before and After TKA

Opioids have traditionally played an important role in pain management for patients after total knee arthroplasty (TKA). However, in light of the growing opioid epidemic, researchers are taking a harder look at the consequences of persistent opioid use—and more importantly, the factors that can predict which patients will be more at risk for opioid overuse following a TKA. Recent research has revealed that one common predictor of persistent opioid use after surgery is persistent opioid use before a total knee replacement.4

Use of Opioids in Post-TKA Pain Management
According to a study that looked at 105 TKA patients, 90% were discharged on oxycodone, 5% on hydromorphone and 1% on hydrocodone/acetaminophen to mitigate pain.1 Despite this popularity, however, opioids come with several disadvantages, including the risk for dependence or addiction, an increase in abuse and diversion, and a variety of undesirable side effects. These can include gastric issues such as nausea and vomiting, constipation and delayed gastric emptying, as well as respiratory depression, dysfunctions of the immune and endocrine systems and hyperalgesia.2

The Link Between Opioid Use Before and After Surgery
Current research has shed light on the potential link between chronic opioid use before and after a TKA. A study that examined the records of 6,653 Veteran’s Administration (VA) patients undergoing a TKA found that 60% had been using opioids before surgery (20% of them for at least 90 days prior to their TKA). 3 Among the prior opioid users is , 69% were still on opioids six months after surgery and 57% for 12 months afterwards. This is compared to patients who were not on these drugs before surgery: only 4% of opioid naïve patients (i.e., patients who had not taken opioids before surgery) were still on narcotics for pain relief after six months. At the 12 month mark, this dropped to 2%. Researchers concluded that, “The greatest risk factor for prolonged post-TKA opioid use is pre-operative opioid use.” 3

Other researchers have found a similar link. One study looked at 574 patients who were undergoing joint surgery (either a total knee or total hips arthroplasty) and assessed them six months afterwards. They found that while only 8.2% of the opioid naïve patients were still on opioids after 6 months, 53.3% of patients who took opioids before surgery were still taking them at the same point.

The researchers note that, even among opioid naïve patients, a small percentage still runs the risk of becoming persistent opioid users. Among this group, researchers found that the strongest predictors of long-term opioid use were higher pain scores on the day of surgery, higher scores on a pain catastrophizing scale and depression. They “hypothesize that the reasons patients continue to use opioids may be due to pain in other areas [other than the affected joint], self-medicating affective distress and therapeutic opioid dependence.” 4

The Consequences of Chronic Opioid Use
Opioid use, especially preceding a TKA, presents a significant challenge for doctors because of the negative consequences that it can have for the patient.

Opioids will likely continue to play a role in pain management after a TKA, however, the problem of persistent opioid use before surgery is common and there are potential negative consequences for the patient due to the number of undesirable side effects. However, it is recommended that physicians educate with patients on a variety of non-pharmacological pain control techniques in order to avoid the consequences of opioid use and to optimize patient outcomes.3

REFERENCES

  1. Hernandez NM, Parry JA, Taunton MJ. Patients at risk: large opioid prescriptions after total knee arthroplasty. J. Anthroplasty. 2017 Aug; 32 (8): 2395-2398
  2. Benyamin R, Trescot A, Datta S, Buenaventura R, Adlaka R, Nalini S et. al. Opioid complications and side effects. Pain Physician. 2008; 11:S105-S120
  3. Hadlandsmyth K, Vanderweg-Sarrazan MS, Lund BF. Risk for prolonged opioid use following total knee arthroplasty in veterans. J. of Arthroplasty. 2017.
  4. Goesling J, Mosen S, Zaidi B, Hassett A, Afton L, Hilliard P, Hallstrom B, Clavin DJ, Brummett CM. Trends and prevalence of opioid use after total knee and total hip arthroplasty. Pain. 2016 June; 57(6): 1259-1265