Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids. EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies. Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively. Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients

Aims. The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures. Patients and Methods. Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses. Results. A total of 98 769 patients were included; 35 701 patients were opioid-naïve, 11 621 used opioids continuously for six months before surgery, and 4558 used opioids continuously for at least six months but did not obtain any prescriptions in the three months before surgery. Among opioid-naïve patients, between 0.76% and 4.53% used opioids chronically postoperatively. Among chronic preoperative users, between 42% and 62% ceased chronic opioids postoperatively. A three-month opioid-free period preoperatively led to a rate of cessation of chronic opioid use between 82% and 93%, as compared with between 31% and 50% with continuous preoperative use (p < 0.001 for significant changes in opioid use before and after surgery in each procedure). Between 5.6 and 20.0 preoperative chronic users ceased chronic use for every new chronic opioid user. Risk factors for chronic postoperative use included chronic preoperative opioid use (odds ratio (OR) 4.84 to 39.75; p < 0.0001) and depression (OR 1.14 to 1.55; p < 0.05 except total hip arthroplasty). With a three-month opioid-free period before surgery, chronic preoperative opioids elevated the risk of chronic opioid use only mildly, if at all (OR 0.47 to 1.75; p < 0.05 for total shoulder arthroplasty, rotator cuff repair, and carpal tunnel release). Conclusion. Chronic preoperative opioid use increases the risk of chronic postoperative use, but an opioid-free period before surgery decreases this risk compared with continuous preoperative use. Cite this article: Bone Joint J 2019;101-B:1570–1577

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed. Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday. Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor

Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

Up to 40% of patients are using opioids at the time of joint replacement surgery in the USA despite emerging evidence suggesting opioids are ineffective for chronic non-cancer pain. Our primary objective was to determine if preoperative opioid use among patient awaiting total knee arthroplasty (TKA) was associated with worse patient-reported outcomes (PRO) measures at one-year follow-up when compared to non-opioid users, after adjusting for age, gender, and comorbidities. The study linked Alberta's Pharmacy Information Network (PIN) data with prospectively collected Alberta Bone and Joint Health Repository administrative data (medical and PRO data) for patients who underwent primary TKA in Alberta from 2013–2015. The PIN contains prescribing information from physician offices and pharmacies across Alberta. Preoperative ‘opioid users’ were defined as having 90-days of consistent opioid use in the 180-days prior TKA, and ‘opioid-exposed’ subjects had recorded opioid prescriptions in the 180-days prior to TKA, but did not meet the definition of an opioid user. Those with no opioid-exposure in the 180-days pre-TKA were deemed a ‘non-opioid user’. We used multiple linear regression to examine how preoperative opioid use (opioid user, opioid-exposed, non-opioid user) impacted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at one year after TKA after adjusting for confounding variables. These included age, sex, preoperative WOMAC scores, comorbidities including depression, diabetes, obesity, stroke, pulmonary disease, renal disease, cardiac disease, liver disease, and overall comorbid burden. Of the 2182 unique cases identified, 151 (7%) were opioid users, 527 (24%) opioid-exposed and 1504 (69%) non-opioid user. Opioid users were more likely to be prescribed strong opioids (e.g., hydromorphone, oxycodone) compared to with opioid-exposed subjects (p < 0 .001) and had a median morphine equivalent dose of 30.7 mg/day compared with the opioid-exposed group (2.2 mg/day, p < 0 .001) in the 180-days prior to TKA. Opioid users, in the 180-days prior to TKA had an active opioid prescription for a mean duration of 153 days (95CI 149, 157) within the 180-days prior to TKA, compared to 34 days (95CI 32, 37) for opioid-exposed (p < 0 .001). In the parsimonious pain and function models, opioid use, lower preoperative WOMAC score, depression, and obesity were associated with worse one-year pain and function. Patients prescribed preoperative opioids had worse WOMAC scores one-year after TKA respectively when compared to non-opioid users, after adjusting for other factors (opioid user pain score: −9.5, function score: −9.4, opioid exposed pain score: −2.6, function score: −3.6, p < 0 .001 for all). Further, opioid users with a concomitant diagnosis of depression had significantly worse one-year postoperative WOMAC scores when compared to non-depressed non-opioid users (scores −14, p < 0 .001 for both pain and function). In Alberta, 31% of patients were prescribed opioids within 180-days before TKA, preoperative opioid use was associated with worse one-year postoperative WOMAC pain and function scores relative to non-opioid users. Our results suggest that strategies to reduce preoperative opioid use could improve patient outcomes after TKA, and support the most recent Canadian opioid prescribing guidelines that attempt to minimize opioid use for chronic conditions such as arthritis

Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.