Preoperative Opioid Use Research Articles

Preoperative Versus Perioperative Risk Factors for Delayed Pain and Opioid Cessation After Total Joint Arthroplasty: A Prospective Cohort Study.

The evolution of pre- versus postoperative risk factors remains unknown in the development of persistent postoperative pain and opioid use. We identified preoperative versus comprehensive perioperative models of delayed pain and opioid cessation after total joint arthroplasty including time-varying postoperative changes in emotional distress. We hypothesized that time-varying longitudinal measures of postoperative psychological distress, as well as pre- and postoperative use of opioids would be the most significant risk factors for both outcomes. A prospective cohort of 188 patients undergoing total hip or knee arthroplasty at Stanford Hospital completed baseline pain, opioid use, and emotional distress assessments. After surgery, a modified Brief Pain Inventory was assessed daily for 3months, weekly thereafter up to 6months, and monthly thereafter up to 1year. Emotional distress and pain catastrophizing were assessed weekly to 6months, then monthly thereafter. Stepwise multivariate time-varying Cox regression modeled preoperative variables alone, followed by all perioperative variables (before and after surgery) with time to postoperative opioid and pain cessation. The median time to opioid and pain cessation was 54 and 152days, respectively. Preoperative total daily oral morphine equivalent use (hazard ratio-HR 0.97; 95% confidence interval-CI 0.96-0.98) was significantly associated with delayed postoperative opioid cessation in the perioperative model. In contrast, time-varying postoperative factors: elevated PROMIS (Patient-Reported Outcomes Measurement Information System) depression scores (HR 0.92; 95% CI 0.87-0.98), and higher Pain Catastrophizing Scale scores (HR 0.85; 95% CI 0.75-0.97) were independently associated with delayed postoperative pain resolution in the perioperative model. These findings highlight preoperative opioid use as a key determinant of delayed postoperative opioid cessation, while postoperative elevations in depressive symptoms and pain catastrophizing are associated with persistent pain after total joint arthroplasty providing the rationale for continued risk stratification before and after surgery to identify patients at highest risk for these distinct outcomes. Interventions targeting these perioperative risk factors may prevent prolonged postoperative pain and opioid use.

Utility of Ultrasound-Guided Erector Spinae Plane Blocks for Postoperative Pain Management Following Thoracolumbar Spinal Fusion Surgery.

The primary objective of this study is to determine if ultrasound-guided erector spinae plane blocks (ESPB) prior to thoracolumbar spinal fusion reduces opioid consumption in the first 24 hours postoperatively. Secondary objectives include ESPB effects on administration of opioids, utilization of intravenous patient-controlled analgesia (IV-PCA), pain scores, length of stay, and opioid related side effects. A retrospective cohort analysis was performed on consecutive, adult patients undergoing primary thoracolumbar fusion procedures. Demographic and baseline characteristics including diagnoses of chronic pain, anxiety, depression, and preoperative use of opioids were collected. Surgical data included surgical levels, opioid administration, and duration. Postoperative data included pain scores, opioid consumption, IV-PCA duration, opioid-related side effects, ESPB-related complications, and length of stay (LOS). Statistical analysis was performed using chi-squared and t-test analyses, multivariable analysis, and covariate adjustment with propensity score. A total of 118 consecutive primary thoracolumbar fusions were identified between October 2019 and December 2021 (70 ESPB, 48 no-block [NB]). There were no significant demographic or surgical differences between groups. Median surgical time (262.50 mins vs 332.50 mins, p = 0.04), median intraoperative opioid consumption (8.11 OME vs 1.73 OME, p = 0.01), and median LOS (152.00 hrs vs 128.50 hrs, p = 0.01) were significantly reduced in the ESPB group. Using multivariable covariate adjustment with propensity score analysis only intraoperative opioid administration was found to be significantly less in the ESPB cohort. ESPB for thoracolumbar fusion can be performed safely in index cases. There was a reduction of intraoperative opioid administration in the ESPB group, however the care team was not blinded to the intervention. Extensive thoracolumbar spinal fusion surgery may require a different approach to regional anesthesia to be similarly effective as ESPB in isolated lumbar surgeries.

Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study.

In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients. This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption. We analyzed 351 patients (mean age 44 ± 11years, BMI 45 ± 8.0kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]). This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.

Persistent opioid and benzodiazepine use after radical cystectomy in enhanced recovery after surgery (ERAS) patients

Opioid use, misuse, and diversion is of paramount concern in the United States. Radical cystectomy is typically managed with some component of opioid pain control. We evaluated persistent opioid and benzodiazepine use after radical cystectomy and assessed the impact of their preoperative use on this outcome. We also explored associations between preoperative use and perioperative outcomes. We used prospectively maintained data from our enhanced recovery after surgery (ERAS) cystectomy database and the Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM) database to identify controlled substance prescriptions for radical cystectomy patients. We separated patients by frequency of preoperative opioid and/or benzodiazepine prescriptions (0, 1, 2+) and used these cohorts to explore persistent use (prescription 3-12 months after surgery) alongside perioperative outcomes. Our cohort included 257 patients undergoing cystectomy at a single institution from 2017 to 2021. Preoperative opioid and benzodiazepine prescriptions were documented for 120 (46.7%) and 26 (10.1%) patients, respectively. Persistent opioid use was observed in 20 (14.6%) of opioid-naive patients (no prescriptions in 9 months prior to surgery) while 13 (19.7%) patients with 1 preoperative prescription and 28 (51.9%) patients with 2 or more preoperative prescriptions demonstrated persistent use. New persistent benzodiazepine use occurred in 6 (2.6%) patients. Overall persistent benzodiazepine use was present in 11 (4.3%) patients. In a multivariable model, preoperative opioid and benzodiazepine prescriptions were associated with persistent opioid use (P < 0.001; P = 0.027 respectively). No association was identified between preoperative opioid or benzodiazepine usage and perioperative outcomes including length of stay, return of bowel function, inpatient opioid usage, inpatient or discharge complications, readmissions, or emergency department visits. Inpatient pain scores were noted to be higher in patients with ≥ 2 preoperative opioid prescriptions (P = 0.037). Persistent opioid use was present in 23.7% of patients, with a new persistent use rate of 14.6%. Benzodiazepine use was less frequent than opioids, with a small number demonstrating new persistent use. Preoperative opioid and benzodiazepine use is associated with persistent opioid use postoperatively. Preoperative opioid and benzodiazepine use did not affect perioperative outcomes in our cohort.

Patient Selection Criteria in Ambulatory Spine Surgery: Single Canadian Provincial Experience

Ambulatory spinal surgery is a care delivery model meant to improve patient outcomes and reduce in-hospital length of stay (LOS). We reviewed the experience of implementing an outpatient spine surgery program in Manitoba, Canada and highlight elements that can be used to reduce LOS and re-presentation to hospital. This is a retrospective cohort study using data from the Canadian Spine Outcomes and Research Network and independent chart review of adult patients undergoing outpatient spinal surgery between 2015 and 2018. Patient demographics, comorbidities, perioperative course, LOS, and readmissions were analyzed. We included 217 patients in this analysis. The mean LOS was 36.2 hours; 71.98% of patients had a LOS <24 hours. A Kruskal-Wallis test by ranks analysis was conducted and identified 7 elements that correlated with prolonged length of stay (>1 day): age older than 55 (P= 0.027), body mass index >25 (P= 0.045), uncontrolled diabetes (P= 0.015), preoperative use of opioid medication (P= 0.024), American Society of Anesthesiologists classification of 3 (P= 0.023), non-minimally invasive surgical approach, and multilevel procedures. Most (94.1%) of the patients with none of these elements (i.e., age <55, low body mass index, normal/controlled diabetes, minimal preoperative opioid use, American Society of Anesthesiologist classification <3, minimally invasive surgical procedure) had a favorable LOS, <24 hours, compared with 84.8% with 1 risk factor, 80.4% of those with two, 69.8% with three, 53.1% with four, and 31.2% with 5 or more. A small number of patients (14.98%) presented to an emergency department within 90 days of their operation, and there was a 6.28% readmission rate. We identified several patient and surgical criteria that correlate with prolonged length of stays following planned ambulatory spine surgery. Our work provides some empiric evidence to help guide surgeons on which patients and approaches are ideal for ambulatory surgery.

Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction

To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR). Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users. Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively. This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use. Level III, retrospective cohort study.

The Effects of Opioid Dependency Use on Postoperative Spinal Surgery Outcomes: A Review of the Available Literature.

There is a lack of evidence to support the effectiveness of long-term opioid therapy in patients with chronic, noncancer pain. Despite these findings, opioids continue to be the most commonly prescribed drug to treat chronic back pain and many patients undergoing spinal surgery have trialed opioids before surgery for conservative pain management. Unfortunately, preoperative opioid use has been shown repeatedly in the literature to negatively affect spinal surgery outcomes. In this review article, we identify and summarize the main postoperative associations with preoperative opioid use that have been found in previously published studies by searching on PubMed, Google Scholar, Medline, and ScienceDirect; using keywords: Opioid dependency, postoperative, spinal surgery, specifically (1) increased postoperative chronic opioid use (24 studies); (2) decreased return to work (RTW) rates (8 studies); (3) increased length of hospital stay (LOS) (9 studies); and (4) increased healthcare costs (8 studies). The conclusions from these studies highlight the importance of recognizing patients on opioids preoperatively to effectively risk stratify and identify those who will benefit most from multidisciplinary counseling and guidance.

Poster 197: Thresholds for Preoperative Opioid Use in Arthroscopic Rotator Cuff Repair that Negatively Influence Postoperative Clinical Outcomes

Objectives: The objective of this study was to evaluate preoperative opioid use along a spectrum to better understand the role that preoperative opioid use has on postoperative outcomes. Methods: A consecutive series of patients undergoing arthroscopic RCR from 2018 to 2020 were included. Preoperative opioid use within one year of surgery was determined using the state prescription drug monitoring program (PDMP). Cumulative morphine milligram equivalents (MME) from prescriptions one year prior to surgery and the number of days the last opioid was prescribed before surgery determined. Postoperative outcomes at 3 and 6 months included visual analog scale (VAS) for pain and American Shoulder and Elbow Surgeons Shoulder Score (ASES). The proportion of patients achieving patient acceptable symptom state (PASS) for VAS and ASES were determined. Multivariate generalized estimating equations models were utilized to determine the influence of preoperative opioid use on postoperative outcome scores with receiver operator characteristic (ROC) analysis. Results: 763 patients (47.6% male) with a mean age of 60.2 + 10.0 years were included. 488 patients (64%) had no history of opioid use one year prior to RCR, while 275 (36%) had an opioid prescription one year before RCR. Compared to patients without preoperative opioid use, patients with preoperative opioid use had an average ASES value 7.9 points lower (p&lt;0.001), and average VAS value 1.0 points greater (p&lt; 0.001). PASS for VAS and ASES at 6 months was achieved in 28% and 56% of patients prescribed preoperative opioids compared to 46% and 59% without. There was no association between the number of days from opioid prescription to surgery for ASES score (p=0.23) nor VAS score (p = 0.37). ROC analysis with MME categories of 0-200, 200-500, and &gt;500 MME yielded an area under the curve of 0.74 for PASS ASES and 0.78 for PASS VAS. Compared to patients with preoperative prescription &lt;200 MME, patients prescribed &gt;500 were 35.7% (p=0.03) less likely to achieve ASES PASS. For every 100 preoperative MME prescribed, ASES score decreased by 0.11 (p=0.001) while VAS increased 0.018 points (p&lt;0.001). For every 100 preoperative MME prescribed, the probability of achieving PASS for VAS decreased by 1.8% (p=0.004). Conclusions: Preoperative opioid use is a risk factor for diminished clinical outcome scores and higher pain following RCR in the early postoperative setting. The risk profile is modified by total preoperative opioid prescription MME as higher preoperative opioid use is associated with lower ASES, higher VAS, and lower likelihood of achieving PASS for VAS and ASES. Preoperative opioid prescription threshold values of 200 and 500 MME negatively worsened clinical outcomes to greater degrees. Patients with increasing preoperative opioid use should be counseled that lower clinical outcomes and higher pain levels may occur following RCR.

Paper 64: Patient Reported Outcomes Associated With “Completely Better” Status After Hip Arthroscopy

Objectives: Contextualizing patient-reported outcomes (PROs) can help to differentiate meaningful outcomes. Measures such as patient acceptable symptom state and minimum clinically important difference have been increasingly investigated in recent years. Assessment of patients’ perception of being “completely better” (CB) after hip arthroscopy has not been studied and may be of particular value for this rapidly growing field. The purpose of this study was to assess the rate of patient-reported CB status 2 years after hip arthroscopy and determine associations with PROs. Methods: An orthopaedic registry at a single institution was retrospectively analyzed. All patients who underwent hip arthroscopy from 2015 to 2020, and had 2 year follow up data were included in this study. Patients were administered Patient-Reported Outcomes Measurement Information System (PROMIS) in six domains, Numeric Pain Score, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) expectations domains and Surgical Satisfaction Questionnaire (SSQ8) preoperatively and at 2 years postoperatively. Patients completed a CB anchor question at 2 years after surgery. Threshold values for PRO scores associated with achieving a CB status were identified with 90% specificity. Variables were selected a posteriori for inclusion into multivariable analysis based off Area Under Curve (AUC) greater than 0.80 on a receiver operating characteristic (ROC) curve. Results: Overall, 29 of the 62 patients (46.8%) reported their condition CB at 2 years postoperatively. There were no differences in demographics of age, sex, BMI, race, prior hip surgery, pre-op opioid use, or smoking status between the CB and non-CB groups (Table 1). The 2-year and change in PROMIS Physical Function, Pain Interference, Social Satisfaction, Fatigue, and Anxiety, and MODEMS Met Expectations, and SSQ8 PROs were significantly better in the CB group than in the non-CB group (Table 2). Numeric Pain Score in the operative hip was significantly better at 2 years in the CB group. There were no differences in preoperative expectations between groups. Thresholds of 2-year PROMIS PF ≥51.3, change in PROMIS PF ≥12, 2-year PROMIS PI ≤46.6, change in PROMIS PI ≤-12.2, 2- year Numeric Pain Score – operative hip ≤1.0, MODEMS Met Expectations ≥ 95.0, and 2-year SSQ8 ≥87.5 were the best predictors of achieving CB status (Table 3). Multivariate analysis of CB status demonstrated that SSQ8 and change in PROMIS Physical Function were independent predictors of CB status when controlling for potential confounding variables (Table 4). Conclusions: Almost half of hip arthroscopy patients reported being completely better 2 years after surgery. Multiple PROs including physical function, pain, and satisfaction were significant associated with CB status. Improvement in PROMIS Physical Function and two-year satisfaction were independent predictors of CB status. This is the first study to assess CB status 2 years after hip arthroscopy and provides contextualization to PROs for orthopaedic surgeons and researchers. [Table: see text][Table: see text][Table: see text][Table: see text]

The Effect of Preoperative Exposure to Benzodiazepines on Opioid Consumption After One and Two-level Anterior Cervical Discectomy and Fusion.

Retrospective cohort. Investigate the relationship between preoperative benzodiazepine exposure and postoperative opioid use in patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion (ACDF). Little is known about the effect of preoperative benzodiazepine exposure on postoperative opioid use in spine surgery. Patients undergoing primary 1 or 2-level ACDF at a single institution from February 2020 to November 2021 were identified through electronic medical records. The prescription drug monitoring program was utilized to record the name, dosage, and quantity of preoperative benzodiazepines/opioids filled within 60 days before surgery and postoperative opioids 6 months after surgery. Patients were classified as benzodiazepine naïve or exposed according to preoperative usage, and postoperative opioid dose and duration were compared between groups. Regression analysis was performed for outcomes that demonstrated statistical significance, adjusting for preoperative opioid use, age, sex, and body mass index. Sixty-seven patients comprised the benzodiazepine-exposed group whereas 90 comprised the benzodiazepine-naïve group. There was no significant difference in average daily morphine milligram equivalents between groups (median: 96.0 vs 65.0, P = 0.11). The benzodiazepine-exposed group received postoperative opioids for a longer duration (median: 32.0 d vs 12.0 d, P = 0.004) with more prescriptions (median: 2.0 vs 1.0, P = 0.004) and a greater number of pills (median: 110.0 vs 59.0, P = 0.007). On regression analysis, preoperative benzodiazepine use was not significantly associated with postoperative opioid duration [incidence rate ratio (IRR): 0.93, P = 0.74], number of prescriptions (IRR: 1.21, P = 0.16), or number of pills (IRR: 0.89, P = 0.58). While preoperative benzodiazepine users undergoing primary 1 or 2-level ACDF received postoperative opioids for a longer duration compared with a benzodiazepine naïve cohort, preoperative benzodiazepine use did not independently contribute to this observation. These findings provide insight into the relationship between preoperative benzodiazepine use and postoperative opioid consumption. Level III.

Preoperative Opioid Therapy Correlated With Increased Rate of Complications in Foot and Ankle Surgery.

The purpose of this study is to determine whether patients with a history of preoperative opioid use will have an increased likelihood of postoperative opioid use and complications after undergoing forefoot, hindfoot, or ankle surgery. A retrospective review was conducted on forefoot, hindfoot, and ankle surgeries between 2015 and 2020 with a single fellowship-trained orthopaedic foot and ankle surgeon at an academic medical center. A total of 326 patients (356 feet) were included with a mean follow-up up of 2.12 (range, 1.00-4.98) years. Data collected included demographics, medical comorbidities, treatment history, complications and reoperation rates, patient-reported outcome measures (eg, Foot and Ankle Outcome Score), and opioid exposure. There were significantly more complications among opioid exposed patients than opioid naïve ones (exposed = 29.41%, naïve = 9.62%; P = .044). Preoperative opioid exposure significantly correlated with postoperative opioid exposure (90-day: r = .903, p < .001; 180-day: r = .805, p < .001), and increased hospital length of stay (r = .263, p = .029). Furthermore, body mass index was a significant predictor of postoperative opioid exposure (90-day: r = .262, p = .013; 180-day: r = .217, p = .021), as was concomitant mental illness (90-day: r = .225, p = .035). Patients with preoperative opioid exposure have significantly more complications and increased postoperative opioid exposure after foot and ankle surgery. Level III: Retrospective cohort study.

Obesity Severity Predicts Patient Dissatisfaction After Total Knee Arthroplasty

BackgroundPatient dissatisfaction has been reported in 15 to 20% of traditional total knee arthroplasty (TKA) procedures. While contemporary improvements may have positive effects on patient satisfaction, these may be offset by increasing obesity prevalence among patients who have knee osteoarthritis. We performed this study to determine whether obesity severity impacts patient-reported TKA satisfaction. MethodsWe compared patient demographic characteristics, preoperative expectations, preoperative and minimum 1-year postoperative patient-reported outcome measures as well as postoperative satisfaction level among 229 patients (243 TKAs) who had World Health Organization (WHO) Class II or III obesity (group A), and 287 patients (328 TKAs) who had WHO classifications of normal weight, overweight, or Class I obesity (group B). ResultsGroup A patients were younger and had more severe preoperative back and contralateral knee pain, more frequent preoperative opioid medication use, and lower preoperative and postoperative patient-reported outcome measures (P < .01). A similar proportion of patients in both groups expected at least 75% improvement (68.5 versus 73.2%, P = .27). While satisfaction was higher than traditional reporting for both groups (89.4 versus 92.6%, P = .19), group A patients were less likely to be highly satisfied (68.1 versus 78.5%, P = .04) and were more likely to be highly dissatisfied (5.1 versus 0.9%, P < .01). ConclusionsPatients who have Class II and III obesity report greater TKA dissatisfaction. Additional studies should help determine whether specific implant designs or surgical techniques may improve patient satisfaction or whether preoperative counseling should incorporate lower satisfaction expectations for patients who have WHO Class II or III obesity.

The Effect of Preoperative Disability, Cognitive Impairment, Frailty and Opioid Use on Acute Postoperative Pain in Older Patients Undergoing Surgery A Prospective Cohort Study

Globally, life expectancy is increasing, leading to more surgeries being performed in older patients. Postoperative pain is associated with complications after surgery. The aim of this study is to explore potential age-related risk factors for acute postoperative pain in older patients undergoing surgery. This was a prospective, single-center study. Patients ≥65 years, with and without disability, as defined by the WHO Disability Assessment Schedule 2.0, undergoing elective surgery, were compared. Primary outcome was the postoperative pain (ie, numeric rating scale (NRS) score) on the first postoperative day. Secondary outcomes were postoperative pain and pain trajectories in patients with and without mild cognitive impairment (MCI), frailty, preoperative opioid use, and new-onset disability after surgery. Between February 2019 and July 2020, 155 patients were enrolled. On the first day after surgery, postoperative pain did not differ between patients with and without disability. NRS scores differed between patients with-, and without MCI on the first (P = .01), and second postoperative day (P < .01). Patients who used opioids before surgery reported higher median NRS score on the first (P < .001) and second (P < .01) postoperative day. Out of a total of 1816 NRS scores, 2 pain clusters were identified. Acute postoperative pain did not differ between patients with or without preoperative disability and frailty in older patients undergoing surgery. Reduced postoperative pain in older patients with MCI warrants further investigation. The PIANO study (Comparison of Postoperative NeurocognitiveFunction in Older Adult Patients with and without Diabetes Mellitus) was registered with www.clinicaltrialregister.nl (search term: Which can predict memory problems after surgery better; blood sugar levels or memory before surgery?). PerspectiveThis study explored risk factors for acute postoperative pain in older patients. No differences in postoperative pain were observed in patients with or without preexistent disability or frailty, however, patients with mild cognitive impairment experienced reduced pain. We suggest to simplify pain assessment in this group and take functional recovery into account.

Opiate use after total hip arthroplasty for metastatic bone disease.

e24132 Background: Metastatic bone disease (MBD) commonly affects the hip and surgical intervention including total hip arthroplasty (THA) may be indicated for pain relief or to improve function. Following THA, patients are often prescribed short courses of opioids for postoperative pain relief. This study investigated postoperative opioid use following THA in MBD patients. Methods: This was a retrospective review of patients using opioids preoperatively who underwent THA for MBD at two institutions between 2009 and 2022. Preoperative and postoperative opioid usage at 6 weeks and 90 days were quantified through calculating daily morphine milligram equivalents (MME) and compared using the sign test. Results: Nineteen primary THA and 11 THA with complex acetabular reconstruction were included. At six weeks, 26 (86.7%) patients were utilizing opiates and at ninety days 23 (76.7%) patients were utilizing opiates. There was a statistically significant difference between median daily preoperative MME compared to daily MME at ninety days (p &lt; 0.001). The only statistically significant association with opioid use at 90 days was opioid use at 6 weeks. Conclusions: To our knowledge, this is the first paper evaluating postoperative opioid use following primary THA in MBD patients. After THA in the setting of MBD, patients exhibit decreased postoperative opioid use.[Table: see text]

Transitional Pain Medicine; New Era, New Opportunities, and New Journey.

Chronic postsurgical pain (CPSP), also known as persistent postsurgical pain (PPSP), is pain that develops or increases in intensity after a surgical procedure and lasts more than 3months. Transitional pain medicine is the medical field that focuses on understanding the mechanisms of CPSP and defining risk factors and developing preventive treatments. Unfortunately, one significant challenge is the risk of developing opioid use dependence. Multiple risk factors have been discovered, with the most common, and modifiable, being uncontrolled acute postoperative pain; preoperative anxiety and depression; and preoperative site pain, chronic pain, and opioid use.

Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy

IntroductionInterruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes. MethodsThis single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression. ResultsOf the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P = 0.009), atrial fibrillation (20.0% versus 3.7%, P = 0.002), preoperative opioid use (30.0% versus 16.7%, P = 0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P = 0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P = 0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P = 0.010), sepsis (13.6% versus 3.7%, P = 0.028), and severe anastomotic leak (18.3% versus 7.4%, P = 0.032). On adjusted analysis, heart disease (AOR 4.26, P = 0.027), BMI <18.5 (AOR 9.83, P = 0.031), and epidural interruption due to hypotension (AOR 3.51, P = 0.037) were associated with severe anastomotic leak. ConclusionsEarly epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.

An individualised tapering protocol reduces opioid use 1 year after spine surgery: A randomised controlled trial of patients with preoperative opioid use.

Persistent opioid use following surgery is common especially in patients with preoperative opioid use. This study aims to determine the long-term effect of an individualised opioid tapering plan versus standard of care in patients with a preoperative opioid use undergoing spine surgery at Aarhus University Hospital, Denmark. This is the 1-year follow-up of a prospective, single-centre, randomised trial of 110 patients who underwent elective spine surgery for degenerative disease. The intervention was an individualised tapering plan at discharge and telephone counselling 1 week after discharge, compared to standard of care. Postoperative outcomes after 1 year include opioid use, reasons for opioid use and pain intensity. The overall response rate to the 1-year follow-up questionnaire was 94% (intervention group 52/55 patients and control group 51/55 patients). Forty-two patients (proportion = 0.81, 95% CI 0.67-0.89) in the intervention group compared to 31 (0.61, 95% CI 0.47-0.73; p = .026) patients in the control group succeeded in tapering to zero 1 year after discharge (p = .026). One patient (0.02, 95% CI 0.01-0.13) in the intervention group compared to seven patients (0.14, 95% CI 0.07-0.26) in the control group were unable to taper to their preoperative dose 1 year after discharge (p = .025). Back/neck and radicular pain intensity was similar between study groups. These results suggest that an individualised tapering plan at discharge combined with telephone counselling 1 week after discharge can reduce opioid use 1 year after spine surgery.

Association of preoperative opioid use and postoperative complications following breast reconstruction

BackgroundPrevious studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). MethodsWe reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. ResultsOf the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69–23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17–59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. ConclusionWe found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.

Preoperative opioid use disorder has a negative impact on the rate of short-term complications following total and reverse shoulder replacement

BackgroundMore than 2 million Americans and 16 million individuals worldwide are estimated to have an opioid use disorder (OUD). It is imperative that we understand the impact OUD has on patients who require surgical procedures. Preoperative OUD has been associated with increased postoperative complications, lengths of stay, and readmissions in elective procedures. The goal of this study was to elucidate the impact that preoperative OUD has on short-term outcomes following total and reverse shoulder arthroplasty. MethodsPatient information was collected using the National Readmissions Database (2016-2018). Persons who underwent anatomic and reverse shoulder arthroplasty were identified using International Classification of Diseases 10th Revision procedural codes (anatomic: 0RRJ0JZ/0RRK0JZ, reverse: 0RRJ00Z, 0RRK00Z). OUD was defined using the following International Classification of Diseases 10th Revision codes: F11.10, F11.11, F11.20, and F11.21. Patient demographics, comorbidity indices (Charlson and Elixhauser), complications, readmission rates, healthcare costs, and lengths of stay were compared between OUD and non-OUD patients. A univariate analysis was first run with OUD as the independent variable followed by a multivariate analysis to identify if OUD was an independent predictor of adverse outcomes. ResultsOne hundred sixty four thousand and five hundred twenty two total patients were identified (OUD: 1098 vs. non-OUD: 163,424). The OUD patients were younger (64.3 ± 10.0 years vs. 69.4 ± 9.5 years, P < .01), had longer lengths of stay (2.5 ± 2.6 days vs. 1.8 ± 2.0 days, P < .01), and had higher cumulative hospital costs ($83,424.88 ± $53,565.26 vs. $73,099.65 ± $47,548.65, P < .01) on average. Univariate analysis revealed that OUD patients had increased rates of respiratory, intraoperative, hardware, and prosthetic complications, dislocations, infection (surgical site and prosthetic), revision surgeries, and 30-day/90-day readmissions (P < .01). Interestingly, through a multivariate analysis, OUD was predictive for less revision surgeries (odds ratio [confidence interval 95%]: 0.69 [0.48-0.99], P = .045) but trended toward being a predictor for increased rates of 90-day readmissions (odds ratio [confidence interval 95%]: 1.28 [0.96-1.72], P = .09). ConclusionOUD patients were younger on average and had increased lengths of stay, healthcare costs, and risks for developing operative, postoperative, and prosthetic complications compared to non-OUD patients undergoing shoulder replacement. However, OUD was not found to be an independent predictor of adverse outcomes. Together, these findings should encourage surgeons to address substance use disorders with all patients preoperatively in an attempt to mitigate potential complications while not identifying OUD as an exclusive operative contraindication.

Prevalence of preoperative opioid usage and its impact on postoperative outcomes: a retrospective cohort study.

Preoperative opioid treatment increases postoperative adverse events. This study was aimed to analyze preoperative opioid prevalence in countries with low opioid consumption. Additionally, the effect of low opioid usage on postoperative outcomes was also investigated. We conducted this single center retrospective cohort analysis in a Japanese university-affiliated hospital to investigate opioid usage and its impact on the duration of postoperative hospitalization and in-hospital mortality. Adult patients who underwent general anesthesia between 2015 and 2020 were included. We extracted the patients' characteristics, surgical information and postoperative outcomes. Subgroup analysis to address opioid dose effect was performed in high and low dose opioid subgroups. Among 20,306 inpatients, 535 (2.63%) patients used opioids preoperatively. Tramadol was the most frequently used opioid. The median morphine equivalent (MME) dose was 15mg/day. Median duration of hospitalization was 18 and 9days in the opioid and non-opioid groups, and in-hospital mortality was 2.06% and 0.42%. Multivariable regression analysis demonstrated that preoperative opioid use was associated with a longer duration of hospitalization and in-hospital mortality. Subgroup analysis demonstrated longer durations of hospitalization in both high (> 30mg/day MME) and low (≤ 30mg/day MME) dose opioid groups, while higher in-hospital mortality was seen only in the high dose opioid group. Preoperative opioid usage was one-tenth of the United States average. Despite its low prevalence and small dosage, preoperative opioid usage was associated with poor postoperative outcomes. Dedicated perioperative interventions to prevent opioid-associated adverse events should be developed even in countries with low opioid consumption.