A, Percentage of patients receiving any opioid prescription within 60 days of discharge after THA and TKA in 2014 to 2017. B, Mean of total opioid morphine milligram equivalent dose prescribed within 60 days of discharge after THA and TKA in 2014 to 2017. C and D, Mean pain scores after discharge by year of surgery for THA (C) and TKA (D).
eAppendix. Supplemental Methodology Description
eTable. Study Cohort Selection
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Shah R, Kuo Y, Westra J, Lin Y, Raji MA. Opioid Use and Pain Control After Total Hip and Knee Arthroplasty in the US, 2014 to 2017. JAMA Netw Open. 2020;3(7):e2011972. doi:10.1001/jamanetworkopen.2020.11972
Potential overprescribing of opioids after surgery may contribute to opioid-related adverse events.1,2 The proportion of opioid-naive patients with a new opioid prescription within 7 days after total knee arthroplasty (TKA) increased from 79.1% in 2004 to 82.0% in 2012.3 The US Drug Enforcement Administration in 2014,4 the US Centers for Disease Control and Prevention in 2016,5 and health systems, state governments, and health payers all implemented myriad policies to restrict opioid overprescribing. The impact of these policies on postoperative opioid prescribing is unknown. We examined rates of opioid prescribing and level of pain control in patients who underwent total hip arthroplasty (THA) and TKA from 2014 to 2017.
This cohort study used the Optum deidentified electronic health record data set, which includes more than 90 million patients from 38 hospital networks and 18 nonnetwork hospitals in the US. The institutional review board of the University of Texas Medical Branch approved this study and waived the need for informed consent because the data were deidentified. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
We selected patients who underwent THA or TKA in an inpatient setting from 2014 to 2017 in the hospital networks (eTable in the Supplement). We analyzed whether patients received any opioid prescriptions from discharge to 60 days after discharge. Among those who received any opioid prescriptions, we calculated the total morphine milligram equivalent dose prescribed in the study period.
We calculated the level of pain at discharge by using a mean pain score for all observations on the day closest to discharge. We used the same procedure to identify the level of pain within 2 months after discharge at each time period: days 7 to 14, 15 to 21, 22 to 29, 30 to 44, and 45 to 60.
We present descriptive statistics on opioid prescription by years and separately for THA and TKA. Modified Poisson regression models were built to assess characteristics associated with receiving opioid prescription within 60 days of discharge. P values were 2-tailed, and statistical significance was set at P < .05. All analyses were performed using SAS statistical software version 9.4 (SAS Institute). Additional details are reported in the eAppendix in the Supplement. Data analysis was performed from November 2019 to May 2020.
Of 236 631 patients, 86 058 underwent THA at a mean (SD) age of 64.48 (11.17) years and 150 573 underwent TKA at a mean (SD) age of 65.99 (9.59) years. A majority of patients were female (139 410 patients [58.9%]) and white (207 011 patients [87.5%]).
From 2014 to 2017, the proportion of patients who received an opioid prescription within 60 days of discharge increased from 81.9% to 91.5% after TKA and 82.0% to 89.7% after THA (Figure). The mean of total morphine milligram equivalent prescribed within 60 days increased for both groups from 2014 to 2015, stayed stable from 2015 to 2016, and decreased from 2016 to 2017 (Figure). The mean (SD) level of pain at discharge remained similar across years after THA (2014, 3.28 [2.02]; 2015, 3.43 [1.96]; 2016, 3.51 [1.94]; 2017, 3.42 [1.92]) and TKA (2014, 3.73 [2.02]; 2015, 3.87 [1.97]; 2016, 3.90 [1.94]; 2017, 3.90 [1.96]). Across years, the trajectory of postoperative pain from 7 to 14 days to 45 to 60 days after discharge was similar for THA and TKA (Figure). The change in mean pain scores across years at the same point in time was always measured at less than 0.5 (on the scale range of 0-10).
Among patients who underwent THA, a more recent year of surgery (2015, adjusted odds ratio [aOR], 1.05 [95% CI, 1.04-1.06]; 2016, aOR, 1.08 [95% CI, 1.07-1.08]; 2017, aOR, 1.09 [95% CI, 1.08-1.10]), higher pain score at discharge (1-3, aOR, 1.06 [95% CI, 1.04-1.07]; 4-6, aOR, 1.07 [95% CI, 1.05-1.08]; 7-10, aOR, 1.05 [95% CI, 1.03-1.07]), insurance with Medicare only (aOR, 1.03 [95% CI, 1.03-1.04]), and insurance with Medicaid only (aOR, 1.03 [95% CI, 1.01-1.04]) were associated with higher odds of receiving at least 1 opioid prescription within 60 days of discharge (Table). Factors that were associated with lower odds of prescription included older age (55-64 years, aOR, 0.99 [95% CI, 0.98-0.99]; 65-74 years, aOR, 0.96 [95% CI, 0.95-0.97]; ≥75 years, aOR, 0.92 [95% CI, 0.91-0.93]) and race/ethnicity (African American race, aOR, 0.97 [95% CI, 0.96-0.98]; Hispanic ethnicity, aOR, 0.93 [95% CI, 0.91-0.95]) (Table). Associations were similar in patients after TKA.
Despite an appreciable decrease in morphine milligram equivalent dose from 2015 to 2017, there was a substantial increase, from 2014 to 2017, in the percentages of patients receiving opioids after THA or TKA, with no clinically meaningful improvement in postoperative pain level at discharge or even up to 2 months after surgery. These findings suggest that the outcomes of policies aimed at curbing postoperative opioid overprescribing after THA and TKA may be limited. Our findings underscore the need to monitor effectiveness of policies in the real-world setting, given the substantial amount of resources devoted to their implementations.
This study has limitations, including its retrospective design, lack of data on whether patients actually used the prescribed opioids, and inability to evaluate outcomes of individual policies and regulations on prescribing. Another limitation is that a relatively small subset of patients is represented in each follow-up period compared with the size of our overall cohort at discharge, possibly leading to an overestimation of pain. In addition, unavailable opioid data among enrollees who went to rehabilitation likely bias our discharge opioid prescribing rate toward an underestimation.
More research is needed on opioid prescribing patterns over time as new policies arise. Such research can inform development of effective approaches to reduce opioid overprescribing and improve postoperative pain control.6
Accepted for Publication: May 19, 2020.
Published: July 30, 2020. doi:10.1001/jamanetworkopen.2020.11972
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Shah R et al. JAMA Network Open.
Corresponding Author: Rahul Shah, BS, School of Medicine, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555 (firstname.lastname@example.org).
Author Contributions: Dr Kuo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Shah, Kuo, Lin, Raji.
Acquisition, analysis, or interpretation of data: Shah, Kuo, Westra, Lin.
Drafting of the manuscript: Shah, Lin, Raji.
Critical revision of the manuscript for important intellectual content: Shah, Kuo, Westra, Raji.
Statistical analysis: Kuo, Westra, Lin.
Obtained funding: Kuo, Raji.
Administrative, technical, or material support: Raji.
Supervision: Kuo, Raji.
Conflict of Interest Disclosures: Ms Lin reported receiving a grant from Bayer Pharmaceuticals and personal fees from Baylor College of Medicine and Milestone Scientific, Inc, outside the submitted work. No other disclosures were reported.
Funding/Support: This work was supported by grants R01-DA039192 and UL1TR001439 from the National Institute on Drug Abuse, National Institutes of Health.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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