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
When patients don’t show up for their scheduled surgery, many costs are incurred that cannot be recouped, including the OR staff, the anesthesiology team, and equipment and medication that have been ordered. Reducing potential “no-shows” is imperative to maximize efficiencies. In addition to “no-shows,” reasons for cancelled surgeries to include scheduling errors, equipment problems, cancellations due to patient medical status, and emergency surgeries bumping medical procedures.
Key predictors of no-shows include prior missed appointments, history of alcoholism or other substance abuse and/or psychiatric issues. Measures can be taken to deter no-shows among patients from low-income background, such as scheduling appointments around public transportation times, educating patients on the benefits of the surgery, and eliminating the fear of uncomfortable procedures that seems to be higher in low-income patients.