Prior opioid use and high intensity postoperative pain increased the risk for delayed postoperative opioid cessation or persistent opioid use after total joint arthroplasty, according to authors of a study published in Pain and Therapy, who called for preoperative risk stratification and targeted interventions to address these risks.
Patients who undergo surgery are at risk of persistent postsurgical opioid use (PPOU) which, in turn, increases the likelihood of developing opioid use disorder or experiencing an overdose. The authors sought to elucidate risk factors impacting postoperative pain resolution and delayed postoperative opioid cessation. Their prospective, observational, single-center cohort study also aimed to identify preoperative vs perioperative factors associated with PPOU via assessment of longitudinal changes in psychological distress.
For the study, the authors asked consenting adult patients scheduled for a total knee arthroplasty (TKA) or total hip arthroplasty (THA) to complete questionnaires before and after their surgeries. The questionnaires assessed pain; opioid use; and mood (depression, anxiety, and anger), with assessments for psychological distress performed via weekly web-based surveys up to 6 months, then monthly up to 1 year after surgery. The primary study outcome was time to postoperative opioid cessation, defined as 5 consecutive days without opioids. The secondary outcome was time to cessation of pain following surgery.
A total of 188 patients were included in the analysis. Mean (SD) participant age was 64.2 (9.5) years, 52.1% of participants were women, 53.7% underwent TKA, and 46.3% underwent THA. Prior to surgery, participants reported moderate preoperative pain at the planned surgical site, with a mean average pain score of 4.2 on the Numeric Rating Scale of Pain. Approximately 38% of participants reported any preoperative opioid use prior to surgery.
Following surgery, 67.5% of participants achieved postoperative opioid cessation. The median time to opioid cessation was 54 days (95% CI, 43-67). Overall, 51.6% of participants achieved postoperative pain cessation, with a median time to cessation of 152 days (95% CI, 118-271).
Preoperative opioid use was significantly associated with continued opioid use after surgery, with every 1-mg increase in preoperative total daily oral morphine equivalent use associated with a 1% reduction in the opioid cessation rate (P =.02). Elevated postoperative pain was an independent risk factor for delayed opioid cessation, with a 3-point increase in average pain score at any time after surgery associated with a 54% reduction in the rate of postoperative opioid cessation.
In terms of potential preoperative psychological/emotional patient factors potentially impacting postoperative pain resolution, the authors found that elevated anxiety symptoms preoperatively were associated with increased risk of delayed resolution of postoperative pain, underscoring the importance of preoperative mood assessment. Preoperative depressive symptoms in the cohort were not associated with delayed postoperative pain resolution.
At any time postoperatively, elevation in pain catastrophizing and in depressive symptoms were independently associated with delayed pain resolution.
Study limitations include the observational design of the trial, which prevented detection of causality between time-varying covariates and outcomes.
In discussing the study, the authors commented that patients with preoperative opioid use who undergo total joint arthroplasty are at greater risk for postsurgery revision, adverse events, and emergency department visits. They noted that their findings “emphasize the importance of screening for preoperative opioid use to identify the patients at highest risk for delayed postoperative opioid cessation” and that “screening may be further simplified by incorporating pain assessments into existing clinical workflows at any time after surgery.”
The authors concluded, “Repeated risk stratification before and after surgery is necessary to identify patients most likely to develop delayed pain and opioid cessation after total joint arthroplasty.” They added that their findings “provide a rationale for the development of targeted interventions pre-surgery to curb persistent opioid use, and post-surgery psychotherapeutic interventions to curb the development of persistent postoperative pain.”
Hah JM, Vialard JDV, Efron B, et al. Preoperative versus perioperative risk factors for delayed pain and opioid cessation after total joint arthroplasty: a prospective cohort study. Pain Ther. Published online August 9, 2023. doi:10.1007/s40122-023-00543-9