Much has been written in recent years about the orthopaedist’s predilection for prescribing opioids, most of which has been aimed at helping us become better stewards of these medications. It is imperative that we continue learning how best to prescribe opioids to maximize their effectiveness in postoperative pain management, while minimizing their many harmful and potentially lethal effects. With some patients, finding that balance is much easier than with others. Learning to identify which patients may struggle with achieving that equilibrium is one way to address the current opioid epidemic.
In the September 18, 2019 issue of The Journal, Prentice et al. identify preoperative risk factors that are associated with prolonged opioid utilization after total hip arthroplasty (THA) by retrospectively evaluating the number of opioid prescriptions dispensed to >12,500 THA patients. Many of the findings are in line with those of previous studies looking at this question. Prentice et al. found that the following factors were associated with greater opioid use during the first postoperative year:
- Preoperative opioid use
- Female sex
- Black race
- Higher BMI
- Substance abuse
- Back pain
- Chronic pulmonary disease
For me, the most noteworthy finding was that almost 25% of all patients in the study were still using opioids 271 to 360 days after their operation. That is a much higher percentage than I would have guessed prior to reading this study. Somewhat less surprising but also concerning was the finding that 63% of these patients filled at least 1 opioid prescription in the year prior to their THA, leading the authors to suggest that orthopaedic surgeons “refrain from prescribing opioids preoperatively” or “decrease current opioid users’ preoperative doses.”
Although some readers may be suffering from “opioid fatigue” in the orthopaedic literature, I encourage our community to continue addressing our role in the current opioid crisis. While I believe that we have changed our prescribing practices since the data for this study were collected (2008 through 2011), we cannot dismiss these findings. The opioid epidemic is multifactorial and has many deep-rooted tendrils in our healthcare system. We owe it to our patients and to the public at large to be as significant a part of the solution as possible.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
A case-control study by Boraiah et al. in the December 2, 2015 JBJS describes a risk-stratification tool that helps predict which patients undergoing total joint arthroplasty (TJA) are likely to be readmitted to the hospital after discharge. The authors used the tool—dubbed the Readmission Risk Assessment Tool, or RRAT—preoperatively among 207 patients who were subsequently readmitted after primary TJA and two cohorts of 234 patients each (one random and one age-matched) who were not.
The total RRAT score for each individual is the cumulative sum of all scores for modifiable risk factors such as infection, smoking, obesity, diabetes, and VTE. Non-modifiable risk factors such as age, sex, race, and socioeconomic status are not included in the scoring system.
The median RRAT score for those readmitted was 3; the median RRAT score for those not readmitted was 1. An RRAT score of ≥3 was significantly associated with higher odds of readmission. Surgical site infection was the most common cause of readmission (found in 45% of the 207 readmitted patients).
The authors note that in the current and future climate of value-based health care, “any unplanned readmission will have financial consequences on the provider and health-care institution”—not to mention the burden readmissions place on patients. While admitting that the RRAT needs to be further evaluated and validated in larger cohorts and that it may not be possible to modify individual risk factors into “an acceptable range” prior to TJA, the authors suggest that risk stratification with the RRAT “can present a ‘teachable moment’ and an opportunity for shared decision-making discussions.”